Essentials of Complementary and Alternative Medicine (June 1999)

Ritual
Rituals are an important aspect of holistic nursing. Holistic nurses can help to create a time for rituals that have specific meaning and to assist others in the art of ritual 
in daily living (
27
). Although there are no absolute rules that should be followed in creating ritual, a few guidelines are useful. A ritual should have a structure—a 
beginning, middle, and end. It helps to plan the details of a ritual carefully in advance (e.g., similar to what one does in anticipation of a special house guest). For 
example, when you are expecting a guest in your home, you give attention to details in a guest room by adding fresh flowers and books of art or poetry at a bedside, 
so that a sacred space is created. Ritual also happens when we create a sacred space to be alone and reflect on healing awareness.
The first phase of a ritual, the  separation phase, is a symbolic act of breaking away from life's busy activities. For example, it may involve going to a quiet room for 15 
to 20 minutes, taking shoes off, sitting on a pillow on the floor, putting on the answering machine, and honoring the silence. A sacred healing place can be made more 
personal with a special object, such as a burning candle, mandala or religious symbol, and to focus on that object brings a sense of calmness.

The second phase of ritual, the transition phase, helps individuals more easily identify areas in life that need attention. It is a time of facing the shadow, the hero's 
journey, where one can recognize the dark and the difficult as one searches for self and for what is real and worthy and in need of healing in the deepest sense. It is 
the time to go into an unknown terrain—the  limen, or the meaning threshold—in which one leaves one way of being to enter into another way of participating.
The last phase of the ritual, the  return phase, allows for a formal release. An individual can put aside or leave old fears, anger, or memories that no longer serve in 
daily living. This phase challenges a person to integrate a new way of acting, choosing, and relating, or to “walk one's talk” of healing awareness. Healing awareness 
is the ability to be present in the moment and to understand the meaning of the moment. In this state of being present, a noninterfering attention allows natural healing 
to flow.
The reader is directed to specific chapters in this book for treatment approaches, recom-mendations, contraindications, preventive or nondiagnostic values, scope of 
practice, and evaluations corresponding to some of the complementary and alternative therapies listed in 
Table 18.2
.
ORGANIZATION
Training
Training in holistic nursing first involves the basic nursing curriculum that leads to becoming a registered nurse; some academic nursing curriculums are more holistic 
than others. A nurse can receive additional training in holistic nursing through graduate education, various continuing education nursing programs, and professional 
nursing organizations.
The AHNA has established the knowledge and clinical competency in holistic nursing through the AHNA Holistic Nurse Certification Program and the AHNA Holistic 
Nurse Certification (HNC) Examination. The prere-quisites for both routes to certification are that the registered nurse must be in good standing and be registered at a 
state level. The curriculum components for the AHNA Holistic Nurse Certification Program and the HNC examination are found in the  AHNA Core Curriculum for 
Holistic Nursing (
28
). The AHNA Standards for Holistic Nursing Practice serves as the blueprint for both certification processes.
The AHNA Holistic Nurse Certification Program is a four-part program that lasts 18 to 24 months, depending on the nurse's pace. The participant learns about holistic 
nursing and caring–healing modalities. A nurse who has experience in holistic nursing may go straight to the HNC examination. On successful completion of the HNC 
examination, an HNC is awarded.
Quality Assurance
Quality assurance in these two certification routes have been established and are maintained by the AHNA Certification Board. The AHNA completed the  IPAKHN 
Survey, a role delineation/job analysis study that defined and validated the professional activities and knowledge requisite for competent holistic nursing practice in 
various practice environments (
29
). The IPAKHN Survey data analysis ensured the adequate content validity for the HNC examination blueprint as well as the percent 
of HNC examination questions that should be apportioned for each content area. The  IPAKHN Survey and the AHNA Core Curriculum for Holistic Nursing both use 
the AHNA Standards of Hol-istic Nursing Practice as the organizational framework.
The successful completion of the AHNA Holistic Nurse Certification Program and the HNC examination are both a personal and a professional mark of achievement. 
HNC certification recognizes the holistic nurse as having the distinction of excellence in the area of holistic nursing. Nurses who complete either process have the 
honor to list HNC (holistic nurse certified) after their name. The legal status and regulations for the practice of holistic nursing, as with use of complementary and 
alternative therapies, are different in each state. Holistic nurses must know which complementary and alternative therapies they are covered to use in their 
professional practice as specified in their state's nurse practice act.
Emerging organizations and professional societies are increasing the number of offerings for holistic nurses in complementary and alternative therapies. The best 
references for these organizations are university nursing programs and their continuing nursing education departments.
Reimbursement Status and Relations with Conventional Medicine
The reimbursement status for holistic nurses is different in each state. Holistic nurses must know their nurse practice act and follow their state guidelines and 
regulations for reimbursement when in independent practice.
Many holistic nurses are joining other allopathic and complementary and alternative practitioners to offer holistic nursing services. Allopathic physicians are beginning 
to honor the mission and work of holistic nurses and are inviting them to join in collaborative practices to improve the quality of health care for their clients.
PROSPECTS FOR THE FUTURE
The prospects for the future are bright for holistic nurses. By the Year 2000, the majority of nurses will likely be practicing in the community, integrating holistic nursing 
and complementary and alternative therapies. Two major challenges are emerging in holistic nursing (
30
). The first is to integrate the concepts of technology, mind, 
and spirit into nursing practice; the second is to create models for health care that guide the healing of self and others.
Holistic nurses will continue to use, examine, and research complementary and alternative therapies that can facilitate healing, and determine which ones work, for 
which conditions, and with what results. They will explore further the values that clients and their significant others attach to complementary and alternative therapies 
and that holistic nurses attach to them. They will also continue to investigate anticipated complications that result from complementary and alternative therapies.
Holistic nurses can reduce the devastating effects of an individual's crisis and illness by using tools for assessing the bio-psycho-social-spiritual human dimensions 
and integrating complementary and alternative therapies. These tools and therapies are bridges for holistic nurses to better understand the emotions and meaning 
involved in clients' illnesses, crises, and life events.
RESOURCES
For information on the American Holistic Nurses Association Certificate Program in Holistic Nursing and the Holistic Nursing Certification Examination:
American Holistic Nurses Association
2733 East Lakin Avenue
Flagstaff, AZ 86004
(520) 526–2196
(800) 278-AHNA
(520) 526–2752 FAX
For audio and education video information on holistic nursing:
The Art of Caring: Holistic Healing Using Relaxation, Imagery, Music
Therapy, and Touch (1995)
Sounds True Audio Tapes
(817) 773–2337
Boulder, CO
AHNA Video on Holistic Nursing (1996)

American Holistic Nurses Association
(800) 278-AHNA
At the Heart of Healing: Experiencing Holistic Nursing (1994)
Kineholistic Foundation
P.O. Box 719
Woodstock, NY 12498
(800) 255–1914/ext. 277
C
HAPTER
 R
EFERENCES
1.
American Holistic Nurses Association description of holistic nursing. Flagstaff, AZ: American Holistic Nurses' Association, 1993.
2.
American Holistic Nurses Association standards of holistic nursing practice. Flagstaff, AZ: American Holistic Nurses' Association, 1994.
3.
Journal of Holistic Nursing. Thousand Oaks, CA: Sage Publications, Inc, 1997.
4.
IPAKHN SURVEY (The role of a holistic nurse: an inventory of professional activities and knowledge statements). Flagstaff, AZ: American Holistic Nurses' Association, 1996.
5.
Dossey B, ed. American Holistic Nurses Association core curriculum for holistic nursing. Gaithersburg, MD: Aspen Publishers, Inc., 1997.
6.
Dossey B, ed. American Holistic Nurses Association core curriculum for holistic nursing. Gaithersburg, MD: Aspen Publishers, Inc., 1997.
7.
McKivergin M. The nurse as an instrument of healing. In: Dossey B, ed. American holistic nurses association core curriculum for holistic nursing. Gaithersburg, MD: Aspen Publishers, Inc., 
1997.
8.
von Bertalanffy L. General systems theory. New York: George Braziller, Inc., 1972.
9.
Lazlo E. The systems view of the world. New York: George Braziller, Inc., 1968.
10.
Dossey B, Guzzetta C. Holistic nursing practice. In: Dossey B, Keegan L, Guzzetta C, Kolkmeier L, eds. Holistic nursing: a handbook for practice. 2nd ed. Gaithersburg, MD: Aspen Publishers, 
Inc., 1995:18–19.
11.
Kuhn C. A spiritual inventory of the medically ill patient. Psych Med 1988;6:87.
12.
Tresolini CP, the Pew-Fetzer Task Force. Health professions education and relationship- centered care. San Francisco: Pew-Fetzer Health Professions Commission, 1994.
13.
Guzzetta C. Holistic nursing process. In: Dossey B, Keegan L, Guzzetta C, Kolkmeier L, eds. Holistic nursing: a handbook for practice. 2nd ed. Gaithersburg, MD: Aspen Publishers, Inc. 
1995:155–187.
14.
Guzzetta C. Holistic nursing process. In: Dossey B, Keegan L, Guzzetta C, Kolkmeier L, eds. Holistic nursing: a handbook for practice. 2nd ed. Gaithersburg, MD: Aspen Publishers, Inc. 1995.
15.
North American Nursing Diagnosis Association, NANDA nursing diagnoses: definitions and classification. St Louis, MO: North American Nursing Diagnosis Association, 1994.
16.
Dossey B, Guzzetta C. Holistic nursing practice. In: Dossey B, Keegan L, Guzzetta C, Kolkmeier L, eds. Holistic nursing: a handbook for practice. 2nd ed. Gaithersburg, MD: Aspen Publishers, 
Inc., 1995.
17.
Burkhardt M. Spirituality: an analysis of the concept. Holistic Nursing Practice 1989;3(3):69–77.
18.
Patient rights. Accreditation manual for hospitals. Chicago: Joint Commission on Accredation of Health care Organizations, 1992 (suppl.spring).
19.
McCloskey J, Bulechek G. Nursing interventions classifications. St. Louis: Mosby YearBook, 1995.
20.
IPAKHN SURVEY (The role of a holistic nurse: an inventory of professional activities and knowledge statements). Flagstaff, AZ: American Holistic Nurses' Association, 1996.
21.
Munhall P. Revisioning phenomenology: nursing and health science research. New York: National League for Nursing Press, 1994.
22.
Lipowski ZJ. Physical illness, the individual and the coping process. Psych Med 1970;1:90.
23.
Dossey L. Meaning and medicine. New York: Bantam, 1993.
24.
Bevis EO. Accessing learning: determining worth or developing excellence—from a behaviorist toward an interpretative-criticism model. In: Bevis EO, Watson J, eds. Toward a caring 
curriculum: a new pedagogy for nursing. New York: National League for Nursing Press, 1990.
25.
Dossey L. Healing words: the power of prayer and the practice of medicine. San Francisco: HarperSan Francisco, 1993.
26.
Dossey L. Prayer is good medicine. San Francisco, CA: HarperSan Francisco, 1996.
27.
Achterberg J, Dossey B, Kolkmeier L. Rituals of healing. New York: Bantam, 1994.
28.
Dossey B, ed. The Amercian Holistic Nurses Association core curriculum for holistic nursing. Gaithersburg, MD: Aspen Publishers, Inc., 1997.
29.
Dossey B, Fusch U, Forker J, et al. Evolving a blueprint for certification: inventory of professional activities and knowledge of a holistic nurse. J Holistic Nurs 1997;15(4):37–56.
30.
Keegan L, Dossey B. Profiles on nurse healers. Albany, NY: Delmar Publishers, 1997.

CHAPTER 19. M
EDICAL
 A
CUPUNCTURE
Essentials of Complementary and Alternative Medicine
CHAPTER 19. M
EDICAL
 A
CUPUNCTURE
Joseph M. Helms
Background
 
Definition
 
History and Development
Principal Concepts
 
Classical Acupuncture
 
Modern Acupuncture
Provider–Patient Interaction
 
History and Physical Examination
 
Differential Diagnosis and Treatment Planning
Therapy and Outcomes
 
Treatment Options
 
Description of Treatment
 
Schedules and Results
 
Treatment Evaluation
Use of Medical Acupuncture
 
Primary Therapy: Musculoskeletal Pain
 
Least Useful Indications
 
Adverse Effects
 
Preventive Value
 
Scope of Practice
 
Adaptability: Acupuncture as Complement and Complements to Acupuncture
Organization
 
Training and Quality Assurance
 
Reimbursement Status
Prospects for the Future
Chapter References
BACKGROUND
Definition
Medical acupuncture is acupuncture that has been adapted for medical or allied health practices in Western countries. Acupuncture is derived from Asian and 
European sources and is practiced in both pure and hybrid forms. The foundation of medical acupuncture is the therapeutic insertion of solid needles in various 
combinations and patterns. The choice of needle patterns can be based on:
Traditional principles, such as encouraging the flow of  Qi (a subtle vivifying energy) through classically described acupuncture channels
Modern concepts, such as recruiting neuroanatomical activities in segmental distributions
A combination of traditional and modern concepts
The adaptability of classical and hybrid acupuncture approaches in Western medical environments is the key to their clinical success and popular appeal.
History and Development
In the United States, acupuncture has been increasingly embraced by practitioners and patients since the landmark 1971  New York Times article by James Reston 
describing his successful postappendectomy pain management with acupuncture (
1
). Before that time, acupuncture had been practiced only in urban Asian 
communities, discreetly and primarily by and for Asians. In the early 1970s, widespread enthusiasm for acupuncture was fueled by reports from physician visitors to 
China who witnessed surgical analgesia using only acupuncture needles. Respect for the technique grew in the medical and scientific communities in the late 1970s, 
when acupuncture analgesia demonstrated a link to the central nervous system activities of endogenous opioid peptides and biogenic amines. Since the 1970s, 
guidelines for education, practice, and regulation in acupuncture have been established and implemented. Also, state, regional, national, and international societies 
have evolved to represent the interests of groups of practitioners.
C
LASSICAL
 A
CUPUNCTURE
 L
ITERATURE
Acupuncture is one discipline extracted from a complex heritage of Chinese medicine, a tradition that also includes massage and manipulation, stretching and 
breathing exercises, herbal formulae, and exorcism of demons and magical correspondences. (See 
Chapter 12
, “Traditional Chinese Medicine,” for a description of 
this entire system.) The earliest major source of acupuncture theory is the  Huang Di Nei Jing (Yellow Emperor's Inner Classic), the oldest portions of which date from 
the Han dynasty in the second century 
BC
. The Nei Jing authors regarded the human body as a microcosmic reflection of the universe, and they believed the 
physician's role is to maintain the body's harmonious balance, both internally and in relation to the external environment. The  Nan Jing (Classic of Difficult Issues) was 
written in the first and second centuries 
AD
, also during the Han dynasty. This text presented a unified and comprehensive system that advanced the theories of points 
and channels and addressed the etiology of illness, diagnosis, and therapeutic needling. The  Zhen Jiu Jia Yi Jing (Comprehensive Manual of Acupuncture and 
Moxibustion), attributed to Huang-Fu Mi in 282 
AD
 and based on the previous texts, is the oldest existing classical text devoted entirely to acupuncture and 
moxibustion (i.e., heating the acupuncture points and needles with smoldering mugwort, a dried herb).
Between the Han dynasty (206 
BC
–200 
AD
) and the Ming Dynasty (1368–1644 
AD
), acupuncture practice was refined and its literature underwent continual exegesis. 
Research, education, clinical refinement, and collation and commentary on previous classics flourished in the Ming dynasty. The  Zhen Jiu Da Cheng (Great 
Compendium of Acupuncture and Moxibustion) of Yang Ji-Zhou, published in 1601, synthesized many classical texts as well as unwritten traditions of practice. This 
text became the most influential medical text for later generations in Asia and Europe. The  Da Cheng was the source of acupuncture information transmitted to Europe 
in the seventeenth through nineteenth centuries via Latin translations by Portuguese, French, Dutch, and Danish missionaries, traders, and physicians traveling and 
working in China and Japan. It was also the primary source translated into French in the twentieth century.
G
EORGE
 S
OULIÉ DE
 M
ORANT
There was a flurry of primitive acupuncture experimentation by physicians in France, England, Germany, Italy, Sweden, and the United States in the first three 
decades of the nineteenth century. This experimentation did not renew itself in Europe until a century later and in the United States until the 1970s. The most 
influential impact on the development of twentieth-century European acupuncture was the work of George Soulié de Morant, a scholar–diplomat engaged in the 
French diplomatic service in China between 1901 and 1917. Soulié de Morant published articles and French translations of Chinese and Japanese medical texts, and, 
on his return to France, taught clinical applications of acupuncture to French physicians. He systematically introduced acupuncture theory from the classical texts to 
the French and European medical community. The commonly used terms meridian and energy both originated in his texts as translations for the two fundamental 
tenets of acupuncture anatomy and physiology. In twentieth-century France and in much of Europe since the 1950s, clinical acupuncture has codeveloped with 
biomedical science. Europe has thus served as another influence for acupuncture approaches that integrate into the practice of conventional Western medicine (
2
).
PRINCIPAL CONCEPTS

Classical Acupuncture
Acupuncture has evolved over two millennia, both through refinements based on treatment responses and through adaptations to changing social situations. The 
language in classical acupuncture texts reflects nature and agrarian village metaphors and describes a philosophy of humans functioning harmoniously within an 
orderly universe. The models of health, disease, and treatment are presented in terms of a patient's harmony or disharmony within this larger order; and these models 
involve the patient's responses to external extremes of wind, heat, damp, dryness, and cold and to internal extremes of anger, excitement, worry, sadness, and fear. 
Likewise, illnesses are described and defined poetically: by divisions of the  Yin and Yang polar opposites (e.g., interior or exterior, cold or hot, deficient or excessive), 
by descriptors attached to elemental qualities (e.g., wood, fire, earth, metal, and water), and by the functional influences traditionally attached to each of the internal 
organs.
A
NATOMY OF
 A
CUPUNCTURE
The classical anatomy of acupuncture consists of energy channels traversing the body. The principal energy pathways are named for organs whose realms of 
influence are expanded from their conventional biomedical physiology to include functional, energetic, and metaphoric qualities. For example, the Kidney supervises 
bones, marrow, joints, hearing, head hair, and will and motivation; and the Spleen oversees digestion, blood production, blood-related functions (e.g., menstruation), 
and nurturing and introspection. Acupuncture anatomy is a multilayered interconnecting network of channels that establishes an interface between an individual's 
internal and external environments and permits energy to move through the muscles and the various organs.
The most superficial of these pathways are the  tendinomuscular meridians, which are an interface between the organism and its external environment. These 
meridians provide the first defense for the body's response to climatic conditions and external traumas. The  principal meridians travel through the muscles and provide 
nourishment to all tissues and vitality for animation and physical activity. The  distinct meridians go directly from the surface of the body deep to the organs, and they 
allow the nourishment and the energy produced by the organs to circulate throughout the body. Finally, a system of pathways called the  curious meridians creates 
connections among the principal acupuncture channels and serves as energy reservoirs for extreme conditions of emptiness or fullness.
These meridians and their connections form a network of energy circulation that is organized into three bilaterally symmetric plates that divide the body into six 
sagittal territories of influence. Each plate manifests the energy derived from four organs as it circulates in their anatomic territory of influence. 
Figure 19.1
 represents 
the schematic organization of one plate in the acupuncture energy circulation. The core rectangle is the principal meridian subcircuit from which the subdivisions of 
energy circulation are derived: tendinomuscular meridians on the surface, distinct meridians going to the organs, and curious meridians creating connections among 
several principal meridian subcircuits. 
Figure 19.2A
 shows the bilateral surface tracing of one principal meridian subcircuit, and 
Figure 19.2B
 gives the organ 
associations, and thus the names, for these energy channels: Kidney–Heart (Shao Yin) and Small Intestine–Bladder (Tai Yang). 
Figure 19.3A
 shows the surface 
location of the Kidney and Bladder tendinomuscular meridians, associated with two of the four organs involved in the Shao Yin–Tai Yang principal meridian subcircuit, 
and 
Figure 19.3B
 shows the deep pathways of the distinct meridians for the same two organs. Each of the three bilaterally symmetrical subcircuits has a similar 
schematic organization. The anatomic territory of influence shifts with the location of its sagittal plate and the organs involved in its energy circulation.
F
IGURE
 19.1. Schematic anatomy of acupuncture energy circulation.
F
IGURE
 19.2. (A) The Shao Yin–Tai Yang meridian subcircuit. (B) Organ associations (energy channels) for the Shao Yin–Tai Yang meridian subcircuit.
F
IGURE
 19.3. (A) Kidney and Bladder tendinomuscular meridians. (B) Kidney and Bladder distinct meridians.