Acupuncture: A Western Physician’s Experience

Introduction

To an American physician, the entire concept of acupuncture is shrouded in a veil of intrigue and mystery. This is partly due to its origins that are deeply seated in a land far away and described in a tongue that is difficult to understand and interpret. The Western physician is skeptical of how a small thin needle placed in an area that is not represented by any dermatome pattern or nerve pathway could have an effect on the human physiology. The theories used in the application of acupuncture are millennia old are more poetic than scientific. Indeed, with the inception of evidence-based medicine that insists on randomized controlled studies as the gold standard, acupuncture with its clinical observations and broad speculations struggles to find a home in American medicine. It is of little wonder, then, that acupuncture in the United States is considered clinical quackery and any witnessed success, chicanery.

Nonetheless, there is something intriguing about acupuncture that appeals to the inquisitive American physician. This curiosity continues to fill acupuncture training schools with board certified, actively practicing, physicians, and clinicians. What is it about acupuncture that tickles our fancy and for some physicians, has a career-changing effect on how they care for their patients?

West Meets East

On July 26, 1971, the New York Times ran an article that would shake the bedrock of Western medicine. Even though it headlined Dr. Christian Barnard’s first heart-lung transplant, there was an inconspicuous article tucked away in the middle of the paper that involved a Times reporter named James Reston who had to undergo an emergency appendectomy while covering a news story in Peking. He tolerated the appendectomy very well but after his spinal anesthetic wore off, experienced considerable postoperative pain and nausea. Instead of narcotics and anti-emetics, he was treated with the insertion of “three long thin needles in the outer part of his right elbow and below his knees” that relieved his abdominal discomfort and pain. This little article created a tidal wave of interest among patients and physicians alike throughout the country. Was it possible that getting stuck with a few needles could cure disease and relieve pain?

The public outcry prompted President Nixon in 1972, with delegates from the National Academy of Sciences and the National Institute of Health, to travel to China to learn more of what acupuncture could offer. Between 1977 and 1984, the analgesic effect of acupuncture was strongly linked to the release of endogenous opioids which prompted the relaxation of physician skepticism and an interest among physicians to matriculate for special acupuncture training. The UCLA School of Medicine, under the tutelage of Joseph Helms, MD would go on to train hundreds of board certified physicians every year in acupuncture. All of this led to the National Institutes of Health forming a 12-member panel with 25 experts from a variety of medical and biomedical fields to pen an official NIH Consensus Statement on the “state of the art information regarding the appropriate use of acupuncture.” This statement was published in 1999 which concluded that promising results have emerged showing efficacy of acupuncture in nausea and vomiting, postoperative dental pain, addiction and stroke rehabilitation, fibromyalgia and myofascial pain syndromes, headache, and menstrual cramps, tennis elbow, carpal tunnel syndrome, and asthma.

Origins

Since the inception of acupuncture predates written history, we are left to speculate on its origins. It is the author’s prediction that scientists 5,000 years ago were no less clever and intuitive than scientists today. These Chinese scientists probably noticed that if they rubbed their temporalis muscles, they could relieve a headache; or rubbing the great toe could make a toothache go away; by eating a certain herb could ease abdominal cramping. They keenly observed that there were certain specific areas on the body that when stimulated or suppressed, would have distinct and reproducible effects on bodily functions. Much like modern neurosurgeons mapping the homunculi of the human cerebral cortex with electrodes, these scientists probed the surface of the body and cataloged the location of each of these points, their usefulness and their ability to relieve pain and cure illnesses. Mappings of these points became the textbook for future acupuncturists to study and memorize.

Even though these ancient Chinese descriptions of disease appear bizarre to a modern day physician, they nonetheless represent thousands of years of experimentation, modification, and application that might be considered genius. Keep in mind, all of this was done without the luxury of having at their fingertips the valuable contributions of Newtonian mathematics, the physics of Einstein or even Gray’s anatomy. Instead of atoms and molecules as the basic elements of life, they formed their theories using the five basic elements that they were able to see and touch; to be specific: fire, earth, metal, water and wood (see Figure 1).

Figure 1.

Instead of atoms and molecules as the basic elements of life, Chinese scientists formed their theories using the five basic elements that they were able to see and touch: fire, earth, metal, water and wood.

They also observed that each of these five elements represented a phase in nature. Just as the seasons would slowly evolve into the next so does the human body, as a part of this cosmic evolution, undergo similar phase forces. The Chinese felt that the human body is but a microcosm of the macrocosmic universe. They witnessed the spring trees slowly be consumed by the hot solar temperatures of summer. The resultant ash would produce a deep rich soil that would fertilize and nourish the earth for the agricultural growing season. Over time, this earth forms the rocks, mountains and ultimately metals. These mountainous rocks then give up the springs of water that cultivate the soil to grow new trees (a.k.a. the Sheng cycle). They likewise observed that each phase has control of the other phases: the water of winter can quench the fires of summer; the wood of spring can be controlled by the metal of the ax; the earth of harvest time can control the water of winter by the building of dams (a.k.a. the Ke cycle).

One of the first written texts involving Chinese medicine was the Yellow Emperor’s Inner Canon or Neijing. The doctrine of the Neijing proposed a life of moderation, equanimity and morality; or simply, “the way” (Tao). Illness and pain are not only a consequence of external forces such as viruses, cancers and diseases but also from internal forces caused by not fully following the Tao. This would not only include a poor diet, smoking and not exercising but also personality traits such as uncontrolled anger, resentment, lust, and envy. Acupuncture allows for the body to come into harmony with these forces and the person to regain “the way” to health. Acupuncture is the embodiment of the holistic approach to medicine as it serves not only to remedy the external derangement of the body but also affect the psychological and spiritual aspect of the individual as well.

Personality

How a patient’s disease is evaluated and treated is strongly dependent on the patient’s personality rather than where the disease or pain is located. Our ancient counterparts observed that all human personalities fall into five distinct categories and assigned each trait to one of the five phases. Again, over years of observation and examination, they could identify typical illnesses and diseases that occurred with each of the five phases; the detection of the personality of that phase allowed them to identify which phase was influencing the disease.

A person who seeks challenges and pushes themselves to the limit, does well under pressure, loves action and movement, and always wants to be the best would be a personality representing the Wood phase (Spring). A Wood person is a multi-tasker who juggles 10 projects at once but can’t complete anyone of them because of their incessant desire to seek new adventures. Whereas these may be laudable traits, this personality can be plagued with being impatient, have volatile emotions including explosive anger, will more often abuse stimulants and suffer from muscle spasms and myofascial pain syndromes. A Fire (Summer) personality relishes in excitement. The Fire person is passionate and sensual, very dramatic, and charismatic. This person is on fire with life and appears tireless in the quest for the zest of life. But if this is allowed to proceed unchecked, they can suffer from agitation and frenzy, nervous exhaustion, insomnia, palpitations, and sweating. The peacemaker is the epitome of all that is maternal; this is the Earth (Harvest) personality. This person wants to be needed, is loyal to a fault, represents security, and safety, and seeks togetherness, serenity, and stability. This person can also be overwhelmed with worry, obsession, overprotectiveness, meddling, lethargy, indigestion and water retention.

The rough, tough Marlborough man, who feels that it is either “his way or the highway” exudes the attributes of the Metal (Autumn) personality. This person lives a life of definition and structure, respects virtue, and authority, lives according to principle and reveres ceremony. The marine who follows their Code or the clergy who would die for their faith are perfect examples of this commendable personality. If not tempered, these forces can make the person indifferent and formal, autocratic, strict and self-righteous. The philosopher best represents the Water (Winter) personality. This person is often very articulate and clever, can be rather critical and scrutinizing, always is in pursuit of knowledge but comes across as timid and shy. Again, if untethered, these people can become very isolated and lonely, appear tactless and unforgiving, suffer from a suspicious nature and become emotionally inaccessible.

Then it is not surprising to find in western medical literature references citing the strong correlations of acupuncture’s five-phase personality paradigm with the Myers-Briggs personality indicators used by psychiatrists today.

Notice that these personality phases have distinct manifestations: suppressed and diminutive or explosive and overwhelming. The Chinese recognized this duality of the world: up or down, earth or heaven, white or black, male or female, on or off, weak or strong. The description of these forces is referred to as “yin and yang.” These forces are not at war with each other but are manifestations of the same force as if on a sliding scale. A yang manifestation of a Fire personality might be fever, passion and agitation whereas a yin presentation would be cold, clammy and apathetic. The goal here is to balance these forces so as not to have a propensity of yin over yang or yang over yin. This is well demonstrated with the Pacqua symbol where yin and yang are mutually entwined in such a way that no matter how you slice this symbol, there will never be a pure yin or pure yang state; the two are always balanced (See Figure 2).

Figure 2.

The Chinese recognized duality of the world: up or down, earth or heaven, white or black, male or female, on or off, weak or strong. The description of these forces is referred to as “yin and yang.”

Meridians

The goal of acupuncture is the maintenance of the smooth and unaltered flow of the vivifying force, referred to as Qi, through specific channels (meridians) to nourish and give sustenance to the body. The food we eat and the air we breathe are transformed into this very rarefied energy source that gives us life. Depending on the religious and cultural milieu acupuncture is being practiced, this term has had different names; such as “spiritus” by the Jesuit missionaries, the Greeks, “pneuma,” the Indians yogi “prana.” Parcelsus use the term “quintessence” and Galvani “animal electricity.” When in this rarefied form, Qi flows smoothly through the meridians and all is well. If there is an obstruction to this flow caused by disease, the Qi backs up and becomes stagnate causing this rarefied gas to coalesce into a liquid and then to a thick sticky phloegm that prevents its flow through the meridians. Masses and tumors build up behind this obstruction causing pain and the hampering of bodily functions. The intent of acupuncture is to effect a change in these meridians so as to restore the flow of the rarefied Qi through the meridians.

Each of the five phases is represented by a hollow yang organ meridian (found on the dorsal or yang side of the body with the Qi flowing caudally from heaven to earth), and a yin solid organ meridian (found the ventral part of the body with the Qi flowing from earth to the heavens). Each meridian has its own specific acupuncture points that in of themselves, have distinct and separate qualities and functions.

The Liver-Gallbladder meridian represents the Wood personality phase and assures smooth movement of Qi to the muscles, tendons, and ligaments. Interestingly, it is also responsible for proper planning and decision making. Any cerebral event from epilepsy to migraine headaches would involve this meridian. The Heart-Small Intestine meridian represents the Fire personality phase which stores Shen (joy and spirit) and is considered the seat of consciousness. The Spleen-Stomach meridian represents the Earth personality phase and is the principal organ of digestion that transforms the food we consume and the air we breathe into Qi. It also governs the blood by keeping it in the vessels and influences thought and concentration. The Lung-Large Intestine meridian represents the Metal personality which is responsible for the formation and movement of Qi. The Kidney-Bladder meridian represented by the Water personality phase is responsible for the storage and nourishment of Qi thereby influencing the energy of all the organs.

The Point and the Needle

Along these sagitally arranged meridians, are the acupuncture points (see Figure 3). These points act as portals to the meridians where the acupuncturist can either activate (stimulate) or inactivate (sedate). The acupuncture point is not just a point on an acupuncture map but is in fact a physically distinct structure. Biopsy of these points reveals a preponderance of lymph vessels and sympathetic nerve fibers. The high salt content of lymph and interstitial fluid might explain the reason why there is a marked drop in the otherwise very high electrical resistance of the skin over these points. Indeed, acupuncture points are often identified using a cutaneous galvanometer.

Figure 3.

The goal of acupuncture is the maintenance of the smooth and unaltered flow of the vivifying force, referred to as Qi, through specific channels (meridians) to nourish and give sustenance to the body. Along these sagitally arranged meridians, are the acupuncture points. These points act as portals to the meridians where the acupuncturist can either activate (stimulate) or inactivate (sedate).

Originally, the ancient acupuncturist would stimulate these points with heat. They would fashion a cigar from the dried leaves of the ubiquitous Asian mudwort plant (called moxa), light it and place it close to the skin creating a comforting warmth (referred to as moxibustion). But when this heat is applied to an acupuncture point, there is a definite deep sensation of an almost primal experience. If the point was in a yin state characterized as cold, clammy and sore, adding heat to the point would stimulate it and effect a positive change. When a point along the meridian was hot to the touch, throbbing and swollen, then leaving that point alone or cooling the area with water would sedate or inactivate this point.

With the refinement of metals and ability to make small sharp objects, moxibustion was replaced with the use of thin needles. The design and construction of the needle is important to its function. The needle is a solid pencil tipped pin with a 30 gauge shaft originally made of steel or iron with a handle made of copper, silver or bronze wrappings. Once placed in an acupuncture point, it can either be stimulate or sedate the point depending on how the needle is manipulated. Modern acupuncturists will stimulate a needle with an electric current. There is now over a century’s evidence of the beneficial effect of electrical stimulation of different tissues. Slow frequency high intensity electrical stimulation of strategically placed acupuncture needles can release periaqueductal midbrain endorphins creating an analgesic morphine-like effect whereas high frequency low intensity can cause the release of intracerebral norepinephrine creating a descending analgesic effect seen with the amitryptiline and cymbalta. Since acupuncture predates these electric contributions to medicine, how did the ancients create these effects? According to the Thomson-Kelvin effect, electrons will flow along a thermal gradient.

One would anticipate, then that if an electric conductor (steel needle) placed across a thermal gradient (room temperature 70 degrees F and body temperature of 98 degrees F) will cause the flow of electrons and polarize the needle with the tip becoming positive to the negative handle (Seebec effect). If the tip becomes positive in relation to this negative handle, the point is sedated or inactivated. If on the other hand, there is a reversal of temperature of handle to tip with the application of heat to the handle, then the tip will become negative relative to its handle. This will tonify or activate the point. The ancient acupuncturists found that they could activate a point by twirling the needle or applying smoldering moxa to the handle. In fact, these manipulations of the needle can create measurable amperage of current across two acupuncture needles.

Case Report

There is no better way of illustrating the application and value of acupuncture than a case report. Lupe Morales (not her real name) is a 20-year old Mexican-American employee of a fast food restaurant who presents with severe and unrelenting migraine headaches located over the side of her head and temporomandibular joint. This headache is associated with intense pain and muscle spasms in her neck and shoulders. Lupe has noticed that extra strength coffee will suppress her headache and she finds that she can’t do without the caffeine stimulant to “get her going” in the morning.

She is studying to be a graphic artist but the long hours in front of a computer screen seems to intensify her neck and shoulder pain which aggravates her headaches. She is thinking of dropping her coursework anyway because she is afraid to face the challenge of hard work and study. She is timid and lacks self-confidence. Her headaches seemed to be associated with her menstrual periods which are normal but she has been known to miss them due to anxiety. She loves dark chocolate and her digestion considered “finicky.” She was acutely myopic at puberty when her headaches began. She has mild spring allergies. Her facial features are flat due to chronic jaw clenching and headaches.

Lupe’s anxious and inhibited affect, the stiffness in her neck and shoulders, and her chief complaint of headaches, point to a Wood personality involving the liver-gallbladder meridian (Jue Yin presentation). That her headaches sometime respond to caffeinated coffee underlines the deficient nature of her problem as caffeine is a strong adrenergic stimulant to the liver and sympathetic nervous system. She is Yin in appearance and emits a desire to be invisible rather than to receive attention.

Treatment is directed to reinforcing her deficient Yin energy in the meridian by placing needles in acupuncture points along the liver and gallbladder meridians and tonifying (stimulating) these points most notably LR 3, LR 14 and GB 34. Liver 3 point is one of the four most important points of the body and is an excellent point for tonification along the meridian. Liver 14 is referred to as a mu point of the liver which is a point that has a direct energy input into the liver which will be very therapeutic to those who suffer from a deficiency in Yin energy. To balance the energy between the Yin solid liver organ and the hollow gallbladder Yang organ of the meridian, GB 34 is also piquered. This point is the strongest of all gall bladder points which influences tendons and muscles. The liver points are connected to an electric stimulator (LR3 (−) and LR 14(+)) and she is given a treatment for 12 minutes.

Examination of her neck and shoulders reveal trigger points that when palpated, cause sudden and intense muscle contraction and pain. Her obvious myofascial pain is treated by piquering these trigger points with small needles and then left without stimulation (to allow the backed up Qi to disperse) for 10 minutes. Palpation after this treatment shows the trigger points to be less active but the large areas of muscle contraction is still very painful to her. For this reason, small glass jars or “cups” are heated and placed on these areas. As they cool, a vacuum in the cup is created thus pulling the skin and muscle into the cup. Thick, dark venous oozing is seen coming from the previous needle punctures during the 10 minutes the cups are applied. The vacuum is then released causing the patient to feel a sensation of release of the spasm and muscular contraction. These muscles are then massaged with herbal creams and heated with a near infra-red lamp for 15 minutes (see Figure 4).

Figure 4.

Small glass jars or “cups” are heated and placed on areas previously punctured by needled. As they cool, a vacuum in the cup is created thus pulling the skin and muscle into the cup. Thick, dark venous oozing is seen coming from the previous needle punctures during the 10 minutes the cups are applied. The vacuum is then released causing the patient to feel a sensation of release of the spasm and muscular contraction.

After the treatment, the patient is noticeably improved with painless range of motion of her neck and shoulders. She remarks that her usual afternoon migraine headache was uncharacteristically absent. She was encouraged to pursue her dreams as a graphic artist and not be frightened to take on some risk in her life. She was given information on Tai Chi classes to help in stretching and strengthening her muscles particularly of her neck and shoulders. QiGong breathing exercises and yoga courses were also encouraged to help reduce her anxiety and strengthen her self-esteem.

Conclusion

As a Western educated anesthesiologist/chronic pain physician who also practices acupuncture, I feel I am in a unique position to evaluate the advantages and disadvantages of acupuncture. I would like to conclude this article with these personal insights.

1. Acupuncture will never replace surgical anesthesia. It can provide significant help in reducing the need of postoperative narcotics and anti-emetics.

2. Acupuncture is not a single treatment. It is meant to be a part of a life-changing holistic treatment modality. Whereas acupuncture applied in focal areas of pain from an acute injury will offer significant relief of pain and a more rapid recovery, for chronic illnesses, acupuncture with other significant dietary and lifestyle changes may take months of visits to fully appreciate its effect.

3. Acupuncture in the St. Louis area is poorly if not compensated by insurance companies; it can become very expensive for the patient.

4. Acupuncture is not voodoo. Its effect is not a placebo response. It is not devil worship.

5. Acupuncture improperly applied by poorly trained practitioners will result in a unsatisfactory results like any other medical modality.

6. In my hands, acupuncture is not an alternative medical discipline but an adjunct or complementary support to western medicine that deserves to be included in the curriculum of every western educated physician.

American Academy of Medical Acupuncture.

by Claudia Harsh, MD

The American Academy of Medical Acupuncture (AAMA) recently celebrated its 25^th anniversary. Founded in 1987, the organization currently represents more than 1,300 physician acupuncturists in North America and many others from around the globe. This premier organization supports its members by encouraging new research and dialogue through conferences, symposia, and special events. Members are held to high standards of training and proficiency.

Physician acupuncturists may apply for membership in the AAMA if they have completed medical school and residency training (seven to ten years post graduate training) and a minimum of 220 hours of acupuncture training (120 hours didactic and 100 hours of clinical training) along with two years of acupuncture practice. A pathway to Board Certification is possible through the American Board of Medical Acupuncture if a case list is created and reviewed, and a certification exam is passed.

Most physician acupuncturists practice their individual specialty of medicine in addition to their acupuncture practice, (e.g. Neurology, Family Medicine, Gynecology, Pain Management, Psychiatry, etc.) This provides the “best of both worlds” blending traditional Chinese medicine principles with Western medical training.

Insurance reimbursement for medical acupuncture varies across the country. A recent roundtable discussion in the journal Medical Acupuncture¹ reviewed the current state of reimbursement. Some communities see no reimbursement for acupuncture while some areas of the country have 20 – 30% coverage of the procedure by insurance companies. Many medical practices figure out what reimbursement strategy can work in their individual communities and apply it to their type of medical practice.

Claudia E. Harsh, MD is the chair of the Education Committee for the AAMA. She is a board certified ob-gyn who practices medicine in Dallas, Texas. In addition to providing gynecology surveillance and survivorship care for Texas Oncology PA she also does acupuncture and integrative medicine at the Virginia Cvetko Integrative Medicine Center at Baylor University Medical Center in Dallas. Dr. Harsh has practiced medical acupuncture for 10 years and is the author of the book “Finding Grace and Balance in the Cycle of Life: Exploring Integrative Gynecology,” published in 2010.

Biography

Thomas G. Johans, MD, is board certified in anesthesiology, pain management, and acupuncture and practices at the DesPeres office of the WAAI Pain Management Services.

Contact: tjohans@aol.com