2.15: Medical Acupuncture

The earliest detailed report on Chinese and Japanese medicine to be written by a European was by Willem ten Rhyne, a Dutch physician who published Dissertatio de arthritide in 1683 (Bivins, 2001; Carrubba & Bowers, 1974). In this book Willem ten Rhyne documented the practice of acupuncture in detail, this was the first time that Europeans were introduced to the practice of acupuncture. Since then, there have been specific branches of acupuncture that have developed in Europe and North America independent of Traditional narratives. The practices are often referred to as medical acupuncture or western acupuncture. Regardless of its theoretical basis and based on the traditional definition, the term acupuncture refers to the actual insertion of a needle (usually a solid needle) into the body.

Figure \(2.15.1\) Sites for the application of acupuncture documented by Willem ten Rhyne.

“The term ‘acupuncture’ is a translation of 针刺术 (zhen ci shu in Chinese pin yin) or in short 针 (zhen), and is literally equivalent to the term ‘needling’ or ‘needling technique’. Based on the traditional and official definition, the term acupuncture refers to the actual insertion of a needle (usually a solid needle) into the body, which describes a family of procedures involving the stimulation of points on the body using a variety of techniques” — (Fan et al., 2016).

Following the European lineage, the concept of medical acupuncture was pioneered by Felix Mann who began to view acupuncture as a form of peripheral nerve stimulation. Fast forward to contemporary times and Medical Acupuncture is a precise peripheral nerve stimulation technique, in which acupuncture needles are inserted into anatomically defined sites and stimulated manually or with electricity. Needle insertion is based on an understanding of anatomy and neurophysiology and acknowledges the fact that, regardless of where the needle is inserted (skin, fascia, muscles, tendons, periosteum, joint capsules, etc.), there will be a number of physiological and psychological responses.

A Neurological Model: Evidence-based clinicians explain the mechanism of action in neurophysiological terms.

Acknowledging that traditional narratives are outdated, medical acupuncture is an approach that is based upon a theory that is inline current scientific understanding of how the body works (Robinson, 2016; White, 2009). Acupuncture originated in a pre-scientific era – Meridians and the concepts of Qi ought to be replaced by systems biology and an understanding of neurophysiology (endogenous opioids, endocannabinoid, and purinergic signaling).

The insertion of an acupuncture needle provides mechanical stimulation of specialized sensory receptors located in the cutaneous and subcutaneous structures. Preferential sites for acupuncture stimulation are associated with areas rich in specialized sensory receptors such as muscle spindles, Golgi tendon organs, ligament receptors, Paciniform and Ruffini’s receptors (joint capsules), deep pressure endings (within muscle belly), and free nerve endings (muscle and fascia). Based on the neurological model, all these areas are highly innervated and as a result there are a number of physiological responses that help modulate the experience of pain. An observed favorable outcome may be explained by overlapping mechanisms in the periphery, spinal cord, and brain (Yin et al., 2017; Zhang et al., 2014).

Acupuncture Research Has Matured

The most comprehensive overview of acupuncture is published in The Journal of Pain, it is a meta-analysis using data from 39 trials and 20 827 patients showing that acupuncture helps with pain and effects exist beyond placebo. In this paper researchers looked at all accumulated randomized controlled trials and examined how acupuncture fared in treating people with chronic pain, what it found was acupuncture often worked better than sham acupuncture and other control groups (Vickers et al., 2018).

As research into acupuncture continues to mature, more clinical practice guidelines, randomized controlled trials and systematic reviews now support the use of acupuncture as part of a multidimensional approach for patients suffering from common musculoskeletal symptoms including:

• Chronic pain (Vickers et al., 2018)
• Acute pain (Cohen et al., 2017; Jan et al., 2017; Murakami et al., 2017; Sakamoto et al., 2018)
• Low back pain (Chou et al., 2017; Foster et al., 2018; Qaseem et al., 2017)
• Non-acute pain after back surgery (Heo et al., 2021)
• Neck pain (Blanpied et al., 2017; Chou et al., 2018; Kjaer et al., 2017)
• Pelvic pain (Franco et al., 2018)
• Tension-type headaches (Busse et al., 2017; Linde et al., 2016)
• Migraines (Busse et al., 2017; Linde et al., 2016; Singh et al., 2020; Xu et al., 2020; Zhang et al., 2020)
• Osteoarthritis (Busse et al. 2017; Lin et al. 2016)
• Postoperative pain (Tedesco et al., 2017)
• Cancer pain (He et al., 2020; Hershman et al., 2018; Mao et al., 2021)
• Aromatase inhibitor-induced musculoskeletal symptoms (Gupta et al., 2020)
• Lateral elbow pain (Gadau et al., 2020)

Auricular Acupuncture for Pain

A specific branch of acupuncture is auricular acupuncture, which has been shown to be an easy to carry out non-pharmacological pain management method that may be of use for patients as a part of a larger multidisciplinary pain management pain strategy (Jan et al., 2017; Murakami et al., 2017; Ushinohama et al., 2016). Acknowledging that traditional narratives outdated auricular acupuncture is being reframed as a form of peripheral nerve stimulation technique in which acupuncture needles are inserted into anatomically defined sites and stimulated manually or with electricity. Auricular acupuncture is interesting because it can be used to stimulate the auricular branch of the vagus nerve (the inner conch of the ear) which may have therapeutic benefits (Butt et al., 2020; Usichenko et al., 2017).

Michigan Medicine: Deconstructing the Legitimization of Acupuncture: How Science Helped Move Acupuncture to Mainstream

The responses to acupuncture are multifactorial – physiological and psychological factors interplay in a complex manner.

The existence of placebo-induced effects does not negate treatment-induced results, the meaning response, therapeutic alliance, ritual, and context all play into the effects, the magnitude of a response may be influenced by mood, expectation, and conditioning (Kong et al., 2018).

The placebo response is real, and it is effective, which is why some may overlook other subtle physiological responses such as sensory gating. In addition to the placebo response the insertion of an acupuncture needle provides mechanical stimulation of specialized sensory receptors located in the cutaneous and subcutaneous structures. This can have an analgesic & anti-inflammatory effect via the inflammatory reflex, endogenous opioids, endogenous cannabinoids and purinergic signaling (Yin et al., 2017; Zhang et al., 2014).

Adopting a neurophysiological explanation can lead to a wider acceptance in both research and clinical settings. Primary mechanism of action is through inhibition of nociceptive processing (bottom-up) and stimulation of endogenous pain inhibitory mechanisms (top-down) (Yu et al., 2020).

Key Takeaways

Acknowledging that traditional narratives outdated, medical acupuncture is an approach that is based upon a theory that is inline current scientific understanding of how the body works. For those who are unfamiliar with the literature, it may be easy to assume that acupuncture is just a placebo. The placebo response is a big part of why patients feel better, but it is also within the realm of reasons that patients have a complex biopsychosocial response to acupuncture that includes but is not limited to placebo.

Acupuncture needles stimulate afferent nerves (A-beta, A-delta, and C fibers), which triggers mechanical, contextual, and neurological responses that help modulate the experience of pain.

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