Essentials of Complementary and Alternative Medicine (June 1999)

P
HYSIOLOGY AND
 P
ATHOLOGY OF
 A
CUPUNCTURE
The classical physiology of acupuncture involves a dozen internal organs that interact to produce basic energy in blood from ingested solid and liquid nourishment. 
These organs then mix in the energy from inspired air and propel the transformed energy and blood through all the body's organs and tissues. The organs are divided 
into six parenchymal, energy-producing organs (solid,  Yin), and six visceral, substance-transporting organs (hollow,  Yang). These organs are coupled into groups 
(one Yin and one Yang) to comprise the three symmetric energy circulation plates.

Pathology in acupuncture involves an early manifestation of disharmony associated with the subtle influences of an organ, a disruption of the  Qi flow in one of the 
subdivisions of the circulation network associated with an organ, or a frank disturbance in an organ's metabolic or transport function.
D
IAGNOSIS AND
 T
REATMENT IN
 A
CUPUNCTURE
Diagnosis in acupuncture involves recognizing the level of manifestation of a disturbance. Premorbid symptomatology is organized according to the organs' subtle 
spheres of influence, in which early energetic and functional symptoms are linked to the organ that supervises the disturbed anatomic region or physiological function; 
for example,Kidney energy supervises head hair, and thus premature graying or balding reflects a deficient Kidney vitality. Obstruction of the flow of energy or blood 
through the principal meridians manifests as musculoskeletal pain in the territory of the channel; for example, the Bladder principal meridian passes through the lower 
back, and thus lumbar pain reflects an obstruction of  Qi and blood flow through that channel. Organ pathology is identified either in conventional biomedical terms or 
as a disturbance in the organ's physiological activities according to acupuncture terms; for example, nephrolithiasis is a disturbance in both Kidney and Bladder 
organs and spheres of influence.
Treatment in acupuncture involves the insertion of needles along the channels of the involved organs to stimulate energy circulation, which can influence the problem 
at its level of manifestation and thus restore energetic balance and organ function.
Modern Acupuncture
Since the late 1970s, acupuncture analgesia has been demonstrated to activate the endogenous opioid peptide system and thereby influence the body's pain 
regulatory mechanism by changing the processing and perception of noxious information at various levels of the central nervous system. Two model systems of 
acupuncture analgesia have been advanced:
Endorphin-dependent system. This involves low-frequency, high-intensity electrical stimulation of acupuncture needles (2 to 4 Hz) that is slow in onset, generalized 
throughout the body, and cumulative on subsequent stimulation (
3
).
Monoamine-dependent system. This involves high-frequency, low-intensity electrical stimulation of acupuncture needles (70 Hz or greater) that is rapid in onset, 
segmental, and not cumulative (
3
).
By combining the neurohumoral models with other observations and speculations about the mechanism of acupuncture's effect, a physiological model is created of an 
acupuncture needle simultaneously activating multiple systems in the body's physiology:
1. The nervous system, which includes peripheral afferent transmission, perivascular sympathetic fiber conduction, and the central neurohumoral and 
neuropeptide mechanisms;
2. The blood circulation system, which transmits locally and centrally biomolecular elements and the biochemical and cellular changes stimulated by 
acupuncture in the periphery;
3. The lymphatic system, which serves as a medium for ionic flow along fascial planes and perivascular interstitial fluid circulation; and
4. The electromagnetic bioinformation system, which consists of static electricity on the surface, ionic migration in the interstitial fluid between the needles and 
as currents of injury at the needled site, and fascial and perineural semiconduction throughout the body (
4
).
This hybrid assemblage of descriptions creates a contemporary working model of a multisystem information network that obliges the medical acupuncture practitioner 
to consider not only classical paradigms to arrive at diagnostic and therapeutic decisions, but also to account for neuroanatomic and neurophysiological parameters. 
These considerations are of special importance in acupuncture's application in pain management, in which knowledge of dermatomal, myotomal, sclerotomal, and 
autonomic innervation patterns is indispensable.
PROVIDER–PATIENT INTERACTION
History and Physical Examination
In a medical acupuncture evaluation, the initial encounter with the patient is similar to that of a conventional allopathic medical interview and examination. The patient 
is encouraged to speak candidly and thoroughly about the presenting problems and his or her background. In addition to a conventional assessment and differential 
diagnosis, the practitioner explores the characteristics and behaviors of the problems in an effort to link them with the gross or subtle spheres of influence of one or 
several internal organs. In the case of musculoskeletal pain problems, the location of the pain is identified neuroanatomically and according to the acupuncture 
channel in whose territory it lies. The goal of the interview is to identify the organs and energy circulation divisions involved in the patient's disorder, and to discern 
whether the association is with subtle symptoms linked to the traditional sphere of influence of the organs, with the trajectory of a meridian through a painful region, 
with a dense organ lesion, or with a combination of these factors.
The patient's past medical history, childhood illnesses, family history, and review of systems are elicited during the interview, and all information is tagged with the 
organ or meridian under whose supervision it falls. During this period, the acupuncturist poses questions of particular importance: Is there a possible cyclicity in the 
appearance of the symptoms? Are there seasonal exacerbations or general seasonal preferences or dislikes? Does the patient have positive or negative flavor and 
color affinities? How do the symptoms respond to external climatic environments? How does the lesion respond to pressure, movement, heat, or cold?
A standard physical examination appropriate for the patient and the problem is undertaken, with several additional acupuncture inspections included. The 
musculoskeletal evaluation includes identification of painful muscle knots and trigger points, as well as subcutaneous nodules and bands overlying contracted 
muscles. Specific reflex points on the front and back of the trunk— Mu points and Shu points—correspond to the organs associated with them. If any Mu or Shu points 
are sensitive to palpation during the physical examination, those findings are also recorded.
In acupuncture, several diagnostic somatotopic systems that microcosmically reflect the internal organs are routinely used to evaluate the balance of relative 
strengths and weaknesses within the organs. The systems most commonly employed are the reflex systems of the tongue, the radial pulse, and the external ear. 
These inspections are undertaken as part of the routine physical evaluation.
Through its color, body, coating, and surface irregularities, the tongue reflects the basic condition and underlying problem of the patient at the time of examination. 
Changes in tongue qualities are easily noted from week to week and often day to day. The tongue serves as an indicator of change in the patients as they evolve 
through illness and respond to medical interventions.
The diagnostic microsystem of the radial pulse provides another means of evaluating the patient's overall condition and of comparing the relative strengths of 
energetic activity in the organs and their meridians. The pulse changes from minute to minute and can therefore be used to verify whether an input had its intended 
effect before continuing or concluding the treatment. The pulses also serve as a subjective measurement from visit to visit, revealing the stability of the changes made 
through the acupuncture treatments.
Evaluation of the external ear confirms findings from the physical examination or other reflex systems, and it may indicate new directions to explore in the interview 
and examination. The diagnostic examination of the external ear includes visual inspection, palpation with a probe, or scanning with a battery-powered electrical 
resistance detector. The external ear can also be used as a treatment system, in isolation or as an adjunct to body acupuncture points.
Differential Diagnosis and Treatment Planning
Before concluding the diagnostic process, a review of past medical records, radiographs, and laboratory studies is undertaken, and appropriate new studies are 
requested to confirm and specify mechanical and organic disorders. From all available information, subtle and gross symptoms and characteristics are organized into 
affinity clusters, and patterns of disharmony are identified. The organ or organ's influence that is most disturbed is then defined, as is the  level of manifestation of this 
greatest disturbance. The energy-functional level of disturbance involves the balance of energetic and metabolic activities of the organs and their spheres of 

influence, including especially their psychoemotional expressions; the  channel-structural level involves skin, fascia, muscles, and bones; and the  organ level involves 
the metabolic or transport functions of the organs themselves. The acupuncturist then decides what division of the energy circulation network gives best access to the 
level of greatest disturbance.
The initial interview affords the acupuncturist an understanding of the nature of the problems and of the patient's constitutional strengths and weaknesses. The ideal 
diagnostic conclusion is a clear perception of the patient's health course: the presenting problems and their origins and the likely future health events. An algorithm of 
treatment approaches is constructed. The acupuncturist must keep in mind the goal of the overall treatment strategy while working with various tactics at each 
session. For example, the immediate treatment plan may address only relief of the most urgent symptoms, and longstanding problems can be addressed after change 
occurs in the presenting symptoms.
T
REATMENT
 D
ESIGN
The first steps in treatment design are to identify the levels of manifestation of the patient's complaints and to establish an order of treating the problems. Treatment 
strategy involves activating the appropriate layers of the energy circulation network to address each problem in its own level of manifestation. A simple strain or sprain 
may need nothing more than dispersion with needles surrounding the local lesion and an activation of the appropriate tendinomuscular meridian. Musculoskeletal pain 
of longstanding duration will need placement of needles around one of the principal meridian subcircuits to encourage energy flow, plus local needles to focus on the 
site of the problem. Such a treatment may involve electrical stimulation of the points needed to move the energy through the subcircuit as well as the local points. 
Psychosomatic or premorbid problems may respond to the needling of several front or back  Mu or Shu points, to a rarefied equilibration treatment based on more 
arcane models of organ and energy interactions, or perhaps to an activation of energy flow through the disturbed principal meridian subcircuit.
It is important to aim treatment at the level of manifestation of the problem being addressed. The circulation levels being activated may be changed during a series of 
treatments to better address the presenting problem or to introduce treatment for secondary problems. It is better to proceed slowly than with vigor, so that the 
patient's response to the treatment can be evaluated properly. As with any other medical intervention, factors influencing the outcome of a treatment include the 
patient's age, the duration and complexity of the presenting problem, presence of concurrent acute or chronic illness, medications, history of surgical interventions, 
lifestyle and personal health factors, and the patient's emotional state and basic vitality. The patient's attitude towards acupuncture usually does not affect the result; it 
is not necessary to believe in acupuncture for it to be effective.
THERAPY AND OUTCOMES
Treatment Options
The author and the majority of physician acupuncturists in the United States use the hybrid model of combining energy movement through the channels with local or 
focusing treatment. This model, known as acupuncture energetics, is derived from European interpretations of the Chinese classics and blended with neuromuscular 
anatomy of trigger points and segmental innervation for pain treatments.  Japanese meridian acupuncture is most akin to the linear energy movement programs 
represented in this chapter, although Japanese practitioners commonly place needles more superficially than do Europeans or Americans.
Of the acupuncture systems currently practiced in the United States,  traditional Chinese medicine, which is taught at the training colleges in China, is the most 
widespread. This approach to acupuncture is linked with prescribing traditional herbs as the core of the discipline and can be effective for many conditions. The 
acupuncture points are selected for their traditional functions to reinforce the goals of herbal therapy, rather than simply to move energy through the circulation 
network.
Five elements acupuncture is another widely practiced discipline, imported from England, reflecting French and other European interpretations of classical 
information. This approach has its greatest value assisting in the repair of problems originating in the psychoemotional sphere.
Three somatotopic systems have established themselves as valuable disciplines, used either as exclusive approaches to acupuncture or as adjuncts to body 
acupuncture. Auricular acupuncture, developed in France, offers a homuncular reflex organization of all body parts on the external ear.  Korean hand acupuncture 
identifies a microsystem on the hand of the complete meridian circulation.  Scalp acupuncture is yet another recent development. There are several systems of scalp 
acupuncture that divide cranial territories into neurological regions corresponding to cerebrocortical influences on the body structures. These somatotopic systems 
appear to be effective for modifying neurological problems that can be elusive to body acupuncture.
Description of Treatment
The acupuncture treatment consists of inserting fine needles into the body in patterns designed to influence the flow of  Qi in one of the subdivisions of the energy 
circulation network. Usually only one energy subdivision is selected to stimulate energy movement, along with a collection of local points to focus the attention of the 
energy movement. Each subdivision of the circulation has a unique therapeutic point combination necessary for activation. The combinations involve the insertion of 
at least three needles—the energy-moving needles—that are usually in the extremities and usually run bilaterally. The focusing needles are inserted at trunk points 
that influence the organs being stimulated, or at muscular points tender to palpation in the region of the pain.
Needles are inserted to the depth necessary to elicit the patient's sensation of  De Qi, or needle grab, a dull ache that radiates from the point. This can be 0.5 to 8 
centimeters, depending on the location. Needles vary from 0.1 to 0.35 millimeters in diameter, and from 1 to 15 centimeters in length.
The patient is positioned comfortably, usually lying supine or prone. The acupuncture needles are inserted and are left in place for 5 to 20 minutes. It is crucial to 
protect the patient from energy depletion during an acupuncture treatment. The older or more fatigued the patient, the shorter the duration of the treatment must be. 
The energy-moving needles may be stimulated when an additional activation of the acupuncture system is desired, such as when the problem is one of deficiency 
according to acupuncture principles or when the patient has low vitality. This stimulation is accomplished by manual manipulation, by heating the needle with burning 
mugwort (moxibustion), or by connecting the needles to an electrical stimulating device.
Focusing needles can likewise be stimulated with manual, thermal, or electrical means. It is common to treat the patient using front, back, and extremity points during 
the course of a single treatment session. This means that the treatment is typically divided into several sections: the energy movement section using extremity points 
to activate flow through the meridians, and the points to focus the energy on one or several organs, or local points to influence a pain problem.
The following is an example of preventive intervention that uses the traditional influences of the organs: A 33-year-old man presents with reports of a general 
diminution of energy, including decreased sexual interest, increased sensitivity to cold weather, mild generalized joint aches, and a new affinity for salt. He is wearing 
a black T-shirt and black underpants and has significant graying at the hair on his temples (symptoms and presentation being features of Kidney influence). His 
medical evaluation and laboratory tests are negative. This case is a premorbid manifestation of weakness in the Kidney sphere of influence. An appropriate treatment 
would be to activate Kidney energy with needles and moxibustion at the  Shu points for Kidney on the back, bilaterally, as the first section of the treatment. The second 
section of treatment could consist of creating an energy flow through the  Shao Yin (Kidney–Heart) and Tai Yang (Small Intestine–Bladder) principal meridian 
subcircuit by placing one needle in the Kidney meridian, one in the Heart meridian, and one in the Bladder meridian, bilaterally in the extremities, and manually 
stimulating and additionally with moxibustion. Each section would last 5 to 10 minutes and would take place in one session.
The local treatments for pain problems can be quite complex because, in addition to honoring the classical directive of encouraging the flow of  Qi and blood through 
the channels that traverse the painful area, the neuromuscular anatomy must be considered. Deliberately searching for and deactivating intramuscular trigger points 
in the region of pain and along the myotomal distribution of the spinal segments involved in the pain is a necessary component of the local treatment. Likewise, 
recruiting the neurological activity of the spinal origins of the dermatomal, myotomal, sclerotomal, and sympathetic innervation of the pain problem is a common local 
treatment for chronic pain. In these cases, electrical stimulation is commonly used, with the frequencies ranging between 2 and 150 Hz.
For example, if the 33-year-old man described in the preceding case also has chronic lumbar pain with an occasional L5 radicular component, the acupuncture 
treatment will consist of an initial energy-moving section involving two needles bilaterally in the extremities on the Kidney meridian, one in the Heart meridian, one in 
Small Intestine, and one in Bladder. The two needles in the Kidney meridian are used to enhance the energetic activity in the subcircuit, and moxa can be applied to 
the other points; this section of the treatment lasts approximately 10 minutes. The second section is the local treatment for the lumbar pain and involves needles 
placed on the Bladder meridian (e.g., at the L2 level [somatic sympathetics for lower extremities], L4 and L5 levels [myotomal and dermatomal levels of pain], and at 

the S2 level [parasympathetics for lower extremities]) to recruit the spinal segments involved in his pain. Electrical stimulation at 14 or 15 Hz can be connected among 
these needles. This second section lasts for 20 minutes.
Schedules and Results
Patient visits are usually scheduled once weekly, although two or three weekly are not uncommon, especially during the initial stages of an acute problem. When a 
favorable response lasts for the entire week between visits, the interval is opened to two weeks. As the response stabilizes for a two-week period, the interval is 
opened again to three weeks, then four. When the symptoms are stable for four weeks, a decision is made as to whether the patient should return for a maintenance 
treatment in another month or six weeks, or call for an appointment only if the condition returns. Patients with chronic pain problems typically require maintenance 
treatments at one-month, six-week, or two-month intervals and—even when responding well to acupuncture—typically need quarterly maintenance treatments. 
Medical problems of lesser severity and chronicity can often be resolved adequately and do not require maintenance treatments.
Treatment Evaluation
Any change during initial treatments—even a transient exacerbation of symptoms—is considered a favorable response. No response to the initial treatment may 
indicate that the therapeutic input was not strong enough, that the problem is deep-seated and requires several treatments to influence, that the treatment design is 
inappropriate, or that the problem is inaccessible to acupuncture. An exacerbation of symptoms after the initial treatment usually indicates that the treatment decision 
is accurate, but that the manipulation or the duration of the needles was too extensive. An examination of diagnostic microsystems, such as the radial pulse and the 
tongue, is another means for the practitioner to subjectively evaluate change in the patient's condition from visit to visit, and thereby better decide if a change in 
treatment is indicated.
With the cumulative effect of treatments, an  enduring improvement is the desired goal. Enduring improvement may mean a thorough resolution of the presenting 
problem or it may mean enabling the patient to function on a plateau of less-incapacitating discomfort. Enduring improvement may also mean that the patient requires 
less medication than at the time of initial presentation. Ideally, a dozen visits are scheduled to follow the course of the disorder and its response to acupuncture. 
Usually the extent of response can be approximated by six or eight visits, but an enduring response often requires the full schedule of visits. After the first dozen 
treatments, the problem and its response to acupuncture are reevaluated and the acupuncturist and patient decide about continuing intensive treatment or 
maintenance treatments, or abandoning the acupuncture intervention altogether.
Acupuncture treatments are as individual as the patients and their responses to acupuncture. It is common to stay with an initial treatment approach for at least three 
or four visits before modifying the approach. It is also common for the patient to report changes in general well-being and vitality, or a reduction in medication, before 
a clear change in the presenting symptoms occurs. If there is no progress by the sixth visit, the acupuncturist may consider including additional modalities to 
complement the acupuncture. It is best not to abandon a case that shows reasonable hope for response to acupuncture before completion of a full trial of twelve visits.