By: Peng, Yu
Behcet's disease, a severe type of recurrent aphthous ulcers, is treated with the administration of corticosteroids and immunosuppressives in Western medicine, but there is a very high recurrence rate. This study looked at the comparative effects of acupuncture treatment in 26 cases and Western drugs in 20 cases treated with this condition. Among the 26 cases in the treatment group, 12 were male and 14 female, ranging in age from 30 to 46 years. The shortest duration of disease was 5 years, and the longest, 28 years. Of the 20 cases in the control group, 9 were male and 11 female, ranging in age from 30 to 45 years. The shortest duration of disease was 5 years, and the longest, 27 years. The location and size of the ulcers were similar in patients of the two groups. The differences in the levels of IgA, IgM, IgE, IgG, C3 and [C.sub.4], and microelements such as Cu, Zn, Fe, and Mg were not statistically significant between the patients of the two groups (P>0.05). In the treatment group, auricular points unilateral Kou (mouth), Gan (Liver), and Shen (Kidney) were pricked with a three-edged needle to let out 1-2 drops of blood. The treatment was given once every two days, with points on the right and left ear used alternately. 3 sessions constituted one therapeutic course. Patients were usually given two courses of treatment. For body acupuncture, No. 28 needles of 2-cun in length were inserted into Taixi KID-3, Ganshu BL-18 and Shenshu BL-23, and then the handles of the needles were connected to a G6805 electroacupuncture stimulator for 30 minutes at 3v output voltage and 80 Hz frequency. The treatment was given once daily, with 10 sessions constituting one therapeutic course. Most patients were given two courses of treatment with an interval of two days between courses. In the control group, transfer factor (2ml) was subcutaneously injected once every week, with 5 sessions (35 days) constituting a course of treatment. In addition, dexamethasone tablet was orally administered in a dose of 0.75 mg t.i.d, with chlorotetracycline ointment applied topically. Results of the treatment were classified as follows. Cured: Disappearance of the triad of uveitis, oral ulcers, genital ulcers and other symptoms after two courses of treatment, with no recurrence in a 12-month follow-up period. Effective: Disappearance of the same symptoms, but with a recurrence at a longer interval, that is, within one year. Ineffective: No improvement noticed in the duration of onset and the interval of the recurrence after spontaneous extinction of the ulcers. Results: Of 26 cases treated by acupuncture, 19 were cured, 5 effective, and 2 ineffective, compared with 2, 16 and 2 respectively of the 20 control group cases. The total effective rate in the treatment group was 92.3% and that in the control group, 90.0%, with no difference in total effective rate between the two groups (P>0.05). However, the cure rate of 73.1% in the treatment group was significantly higher than the cure rate of 10.0% in the control group (P<0.01). The electroacupuncture also appeared to have a role in enhancing the absorption and reducing the excretion of plasma Zn as higher levels of zinc were found in the patients with the best remission of symptoms.
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Rabu, 28 Januari 2009
The safe use of difficult & dangerous acupuncture points
By: Grant, Alicia,Bo-Ying Ma
Safety is an important area of both public and medical concern. Following the vigorous growth of acupuncture in the west, more attention has been paid to recent reviews of adverse events. This does not need to surprise us; as far back as the Tang dynasty in China a famous author Wang Tao wrote a book called Wai Tai Mi Yao (A Medical Selection from the Secret Collection of the Royal Library). One sentence reads "Needles can kill people but cannot save dead peoples' lives". Later many scholars criticised this sentence because Wang Tao was a director of the Royal Library and not an acupuncturist. In fact it was not his 'invention'--it is a quote from the Ling Shu (chapter 60). This sentence was intended to warn practitioners to be careful to use needles safely and to learn TCM theory and technique in its entirety--it does not mean acupuncture is dangerous or useless.
However, there are some acupuncture points which are difficult and potentially dangerous to needle if one does not have a good technique. In the past, textbooks had no special chapter listing such points. Only two relatively modern books, each called "The Prevention and Treatment of Acupuncture Accidents", published in Chinese in 1988 and 1996, contain one chapter on the acupoints in ancient Chinese acupuncture books that some doctors regarded as requiring special caution. Our paper aims to explain clearly how to use these points safely. A knowledge of anatomy and pathology is essential. Good technique includes the exact angle and accurate depth of insertion. This can avoid many accidents.
From the anatomical viewpoint
In general a dangerous acupoint means that it is near important organs, nerves or arteries.
The head and face area
* Jingming BL-1 is near the ophthalmic and angular arteries and veins. With the eye closed the patient is asked to look laterally away from the side being needled, the eyeball is gently rolled aside and held with one hand and the needle inserted 0.3-0.5 cun perpendicularly along the orbital wall. No manipulation is performed.
* Chengqi ST-1 has branches of the infra-orbital and ophthalmic arteries and veins. Insertion is perpendicular, 0.3-0.5 cun along the infra-orbital ridge, and before insertion the patient is asked to look upwards and the eyeball is gently pressed upwards with a finger of the practitioner's other hand. The extra point Qiuhou (M-HN-8) is often used in preference. No manipulation is performed.
* Tinghui GB-2, Ermen SJ-21 and Tinggong SI-19 are near the auricular branches of the superficial temporal artery and vein. Palpate to feel the pulse so that it may be avoided, and needle to a depth of 0.3-0.5 cun.
* Some acupoints are near the medulla oblongata, e.g. Fengchi GB-20, Fengfu DU-16 and Yamen DU-15. At Fengchi GB-20 insertion should be perpendicularly 0.5-1.0 cun towards the tip of the nose. For the other two potentially dangerous points, insertion is perpendicular to the same depth. Deeper insertion could cause loss of consciousness and the needle, if angled towards one side, may injure the vertebral artery, causing headache and dizziness.
The neck
* Renying ST-9 lies very close to the carotid body and the carotid sinus. Interference with the former will affect respiration and with the latter cause a lowering of blood pressure which may lead to loss of consciousness. Insertion should be perpendicular to a depth of 0.2-0.4 cun.
* Tianrong SI-17 is close to the common carotid artery, which should be palpated and pressed aside. Insertion is perpendicular 0.3-0.5 cun.
* Tiantu REN-22 lies in front of the trachea and the needle is first inserted perpendicularly in the middle of the suprasternal fossa 0.2-0.4 cun. If the trachea were perforated it would produce a strong cough but not a pneumothorax. The needle may then be directed downwards along the posterior aspect of the sternum to a depth of 0.5-1.0 cun. If it should be angled sideways however, it could touch either the lung, resulting in a pneumothorax, or the aorta, producing haemoptysis with possible fatal consequences.
The chest
The lung in a thin person lies 10-20mm under the skin and there is danger of pneumothorax if the needle punctures the lung or pleural cavity. There are 90 incidents of this in the literature. The following points need special care because if the angle and depth are not correct the lung may be punctured.
* Jianjing GB-21. On the anterior aspect of the chest (at the mid-clavicular line) the pleural cavity extends down to the 8th intercostal space, and the upper lobe of the lung rises into the supra-clavicular fossa on inspiration. Although Jianjing GB-21 is usually needled perpendicularly to a depth of 0.3-0.5 cun, the authors prefer to pick up the trapezius muscle and insert the needle obliquely, then release the muscle, especially with emaciated patients.
* Quepen ST-12 and the adjacent extra point Jingbi (M-HN-41) (1) lie near the lung and are needled obliquely and posteriorly to a depth of 0.2-0.4 cun.
* Zhongfu LU-1 and Yunmen LU-2 lie just outside the lung but oblique insertion towards the lateral aspect of the chest is recommended to a depth of 0.5-0.8 cun.
* Tianchi P-1 is inserted obliquely only 0.2-0.4 cun.
* Riyue GB-24 is inserted obliquely 0.3-0.5 cun.
* Points Bulang KID-22 to Shufu KID-27, Shidou SP-17 to Zhourong SP-20 and Qihu ST-13 to Rugen ST-18 should be needled obliquely laterally to a depth of 0.3-0.5 cun.
* On the axillary line, laterally, the pleural cavity extends down to the 10th intercostal space. All points over this area should be needled obliquely to a depth of 0.3-0.5 cun, for example Dabao SP-21, Yuanye GB-22 and Zhejin GB-23.
The back
* On the posterior chest (back), under the thoracic spine, the pleural cavity extends to the twelfth rib at the lateral border of the erector spinae muscles, and this includes acupoints on both Bladder channel lines, namely Dazhu BL-11 to Weishu BL-21 and Fufen BL-41 to Weicang BL-50, which should be needled obliquely 0.3-0.5 cun. Similar care needs to be taken with acupoints Sanjiaoshu BL-22 to Shenshu BL-23 and Huangmen BL-51 to Zhishi BL-52 as these lie over the kidney area of the back.
* On the Small and Large Intestine channels, Jianwaishu SI-14, Jianzhongshu SI-15 and Jugu L.I.-16 lie over the lung and should therefore be needled obliquely to a depth of 0.3-0.6 cun.
The abdomen
In general, points on the abdomen are safe when not needled more than 0.5-0.8 cun deep. When the urinary bladder is full, deep needling at points Qugu REN-2 and Zhongji REN-3, and even Guanyuan REN-4, Shuidao ST-28, Guilai ST-29, Henggu KID-11, Dahe KID-12 and Qixue KID-13 may penetrate the bladder causing risk of infection. Wherever possible the patient should be asked to empty the bladder before needling. In cases of urinary retention scrupulous clean needle technique should be observed.
Infants
The top of the head should not be needled before the anterior fontanelle has closed (at up to 2 years old).
Blood vessels
It is advisable to palpate before needling to avoid certain blood vessels e.g. the radial artery at the wrist at Taiyuan LU-9, the dorsal pedal artery at the foot at Chongyang ST-42 (Chongyang), the superficial temporal artery at the ear at Tinghui GB-2, Ermen SJ-21 and Tinggong SI-19, the carotid artery at the neck at Renying ST-9 and the angular artery near the eye at Jingming BL-1. Also, when needling Jiquan HE-1 the axillary artery should first be palpated to avoid puncturing it. Insertion is perpendicular, 0.5-1.0 cun.
Anatomical aberrations
* Sternum: 5-8% of people in the western world have a sternal foramen, which may lie beneath the point Shanzhong (Tanzhong) REN-17. This does not show on X-ray but only on a CT scan, nor is it palpable as it is covered by a thin layer of membrane. Penetration through the sternal foramen may lead to a cardiac tamponade; seven instances have been recorded, including one fatal case in Norway. The needling depth for Shanzhong REN-17 should be no greater than 2 cm using horizontal (transverse) needling technique.
* Blood vessels: when palpating for the radial artery before needling Taiyuan LU-9, it may be found to be absent in a small minority of subjects. This is usually due to an anatomical aberration whereby the radial artery has bifurcated and the larger branch is then palpable between Lieque LU-7 and Yangxi L.I.-5. In TCM this is called "fan guan mai".
From a physiological viewpoint
* Pregnancy: Do not needle Sanyinjiao SP-6, Hegu L.I.-4 and Kunlun BL-60 at any stage of pregnancy unless the patient is overdue and the purpose is to induce labour. Zhiyin BL-67 should also not be needled during pregnancy unless you want to turn a foetal breech position at 32+ weeks.
In the Lei Jing Tu Yi (by the Ming Dynasty author Zhang Jing Yue) it was mentioned that Jianjing GB-21 should not be used during pregnancy, but is indicated for difficult labour. In 1981 an article in the journal Jiang Xi Zhong Yi Yac (2) reported that Jianjing GB-21 was very successful for preventing vomiting, including morning sickness--using only that single point. In our experience Jianjing GB-21 is effective for morning sickness but we would only recommend that it be used by an experienced acupuncturist when other methods have failed.
During the first 3 months of pregnancy do not needle points on the lower back such as Baliao (Shangliao BL-31 to Xialiao BL-34), and avoid using the auricular point Uterus (Zigong). After the third month do not needle points on the lower back or abdomen, such as Qugu REN-2, Zhongji REN-3 and Tianshu ST-25, and in addition after the fifth month avoid points Xiawan REN-10 to Zhongwan REN-12, although the latter may be needled, with shallow insertion and no manipulation, for stomach pain.
In Chinese textbooks since the 1980s it has been emphasised that Sanyinjiao SP-6, Hegu L.I.-4, Kunlun BL-60, Jianjing GB-21, Qugu REN-2, Zhongji REN-3 and auricular point Uterus, which are all contraindicated in pregnancy, should also be avoided during menstruation unless one is actually treating an abnormal menstrual condition.
* Weak, debilitated, hungry, thirsty or stressed patients have an increased tendency to faint. Allow them to rest, eat or drink first. Avoid using strong points such as Fengchi GB-20, Quchi L.I.-11, Hegu L.I.-4 and Zusanli ST-36 and avoid manipulation of the needle.
Any patient may faint in response to needling. When inserting needles the practitioner should observe the patient's face for tell-tale signs of pallor or sweating and all patients should be asked to report if they feel nauseous or dizzy. All patients are preferably treated on a treatment couch, lying or supported in a sitting position, both because they will be less likely to faint when supine and because the first action in case of fainting must be to remove the needles, and this can be difficult if they have slumped to the floor from a chair. They may also injure themselves falling. If faintness is reported or observed, the top of the treatment couch can be quickly lowered, increasing circulation to the head.
From a pathological viewpoint
* Bleeding tendency: this may occur with patients on warfarin or else on long-term cortisone treatment which thins the skin. Haemophilia is a total contraindication to acupuncture. As far as cortisone is concerned, in our experience, injections of a cortico-steroids into a joint will render acupuncture of that joint ineffectual for several weeks
* Scrupulous clean needle technique should be observed when needling points in the potentially dangerous triangle formed by Yintang (M-HN-3) and bilateral Dicang ST-4, as well as at Jingming BL-1, especially when treating facial skin infections such as acne. If the posterior wall of the frontal sinus is infected, infections of the central nervous system can result. This invasion may occur through direct invasion of venous channels and can spread to the skull by septic thrombophlebitis via the valveless veins of Brechet and can be life-threatening. In the area of Jingming BL-1 veins link to the cerebral veins. In western medicine the triangular area bordered by the middle of the eyebrows and the corners of the mouth--approximating to Yintang (M-HN-3) and Dicang ST-4--is regarded as especially susceptible to the introduction of infection via the veins.
* Enlarged organs: the liver, spleen, gall bladder, kidney and heart may all be enlarged due to disease, and all practitioners should have sufficient training in palpation to determine if this is so. When the liver or spleen are enlarged, take care with Jiuwei REN-15, Juque REN-14, Jingmen GB-25, Qimen LIV-14, Burong ST-19, Chengman ST-20 and Liangmen ST-21, which in this case should be punctured obliquely 0.3-0.5 cun. The kidney, if not greatly enlarged, will not be endangered by needling nearby points at a correct depth. If greatly enlarged, the patient's pathology will reflect this, and extreme caution should be exercised with local and adjacent needling.
* Epidemic disease: here it is the acupuncturist who needs to take care not to contract the patient's disease, e.g HIV or hepatitis B and C, by accidentally pricking themselves when removing the needles.
* Patients with pacemakers may not be given electro-acupuncture to the chest area.
* The following points may cause faintness in some people: Zhongzhu SJ-3, Waiguan SJ-5, Hegu L.I.-4, Quchi L.I.-11, Shousanli L.I.-10, Jianyu L.I.-15, Renying ST-9, Tianzong SI-11, Tianjing SI-13, Jianwaishu SI-14, Fengchi GB-20, Jianjing GB-21, Yanglingquan GB-34 and the auricular point adrenal. This is usually because they have a strong sensation or are particularly sensitive.
Causes of risk
From consideration of the above guidelines and from analysing reports of accidents with acupuncture, we can define the following main risk factors:
* inadequate training in acupuncture
* limited knowledge of anatomy or of certain physiological or pathological conditions
* failure to check for abnormal anatomy
* poor needling technique (depth and angle or stimulating too strongly)
* inadequate knowledge of records in ancient books or recent articles
* not paying attention to the patients' condition when they arrive
Safety can be guaranteed
The principle is to understand and remember why a point can be dangerous; every risk can be avoided if due care is taken. There is no need to be apprehensive: the British Acupuncture Council recently surveyed 34,407 treatments for adverse effects (3). There was an underlying serious adverse effect rate of between 0 and 1.1 per 10,000 treatments. A total of 43 minor adverse effects were reported, a rate of 1.3 per 1,000. A survey by Exeter University of 31,822 treatments by members of BMAS (British Medical Acupuncture Society) and the AACP (Acupuncture Association of Chartered Physiotherapists) also resulted in 43 minor adverse effects (4). Among the 43 adverse effects reported by each, most complaints were of a few common short-term symptoms that usually automatically disappeared, some of which are really regarded by acupuncturists as positive, such as a feeling of relaxation (11% of the 43) and feeling energised (6.6%). However even if acupuncture is so demonstrably safe we still need to be cautious for the patients' benefit and should remember that unexpected accidents have occurred. By avoidance of the risk factors, safety can be guaranteed.
Regarding needling technique, we would like to emphasise the following:
* Check that the needles are not in close proximity to organs or arteries.
* Consider the patient's build with regard to depth of needling. It is noted in the Huang Di Nei Jing (Yellow Emeror's Classic of Internal Medicine) that the recommended depth of insertion is for a patient of average build. All cun measurements refer of course to the patient's cun, not the acupuncturist's, who should check their hands against the patient's.
* If it is possible for the needle to touch a bone at a special point, e.g. Shanzhong REN-17 but it has not done so at the normal recommended anatomical depth, do not insert deeper: this is how the cardiac tamponade accident occurred in Norway. This also applies to Tianzong SI-11 as the scapula can also have a foramen.
* If the skin is lifted on insertion of the needle, penetration of the organ can be avoided.
* On the chest and back over the lung the angle of insertion is oblique or horizontal. The tip of the needle is usually directed obliquely towards the midline on the urinary bladder channel and obliquely and laterally on all other channel points passing over the trunk.
* When needling points around the eye, the patient is asked to look in the opposite direction to the point being needled and the practitioner gently holds the eyeball in that position while carefully inserting the needle. The needle is not retained for very long.
* Points near arteries should be palpated to ascertain the exact position of the artery and one finger should press against the artery while the other hand inserts the needle. Following the above techniques will ensure that your practice will be safe and effective.
Notes
(1) Jingbi M-HN-41 is located 1 cun superior to the junction of the medial third and lateral two thirds of the clavicle, at the posterior borer of the sternocleidomastoideus.
(2) Jiang Xi Zhong Yi Yac (1) 39:1981.
(3) MacPherson H. et al., British Medical Journal, 2001, 323:486-487.
(4) White A, Hayhoe S. et al. British Medical Journal 2001,323:485-6.
Source texts
(1) Huang Di Nei Jing, Ling Su, People's Health Press, 1963.
(2) Wang Tao, Wai Tai Mi Yao, People's Health Press, 1955.
(3) Huangfu Mi, Zheng Jiu Jia Yi Jing, People's Health Press, 1956.
(4) Sun Simiao, Bei Ji Qian Jin Yao Fang & Gian Jin Yi Fang, People's Health Press, 1955.
(5) Wang Weiyi, Tong Ren Shu Xue Zhen Jiu Tu Jing, People's Health Press, 1955.
(6) Wang Zhizhong, Zhen Jiu Zi Shen Jing, Shanghai Science & Technology Press, 1959.
(7) Xu Feng, Zhen Jiu Da Quan, People's Health Press, 1958.
(8) Gao Wu, Zhen Jiu Ju Ying, Shanghai Science & Technology Press, 1961.
(9) Yang Jizhou, Zhen Jiu Da Chen, People's Health Press, 1983.
(10) Wu Qian, Yi Zhong Jing Jian, People's Health Press, 1957.
(11) Yang Jiasan et al, Shu Xue Xue, Shanghai Science & Technology, 1984.
(12) Zhen Jiu Xue, People's Health Press, 1993.
(13) Zhang Ye et al, Shi Yong Ling ChuangZhen Jiu Xue, Shanghai Medical University Press, 1998.
(14) Zhang Ren et el, Zhen Jiu Yi Wai Yu Fang Ji Chu Li, Shanghai Science & Technology, Press, 1988.
(15) Wan Xiuying et al, Zhen Jiu Yi Wai Ji Fang Zi, Shandong Science & Technology Press, 1996.
(16) Lewith, G T, MacPherson, H . Reporting Adverse Events Following Acupuncture, Physiotherapy, 2001; 87.1.
(17) Peuker, E T, 'The need for practical courses in anatomy for acupuncturists'. FACT 2: 194. (1997).
(18) Peuker, E T, Fischer G, Filler T J, 'Facial vein terminating in the superficial temporal vein. (A potential risk for acupuncture in the face).'
(19) Ernst E, White AR editors, Acupuncture--a scientific appraisal. London: Butterworth-Heinemann, 1999; p.128-52.
(20) Halvorsen T B, Anda, S S, Naess, A B and Levang, O W. 'Fatal cardiac tamponade after acupuncture through congenital sternal foramen', Lancet,1995; 345, 1175.
(21) Ernst E, White A . 'Life-threatening adverse reactions after acupuncture? A systematic review'. Pain, 1997; 71: 123-126.
(22) House of Lords Select Committee 6th Report on Complementary and Alternative Medicine, London, The Stationary Office, 2000.
(23) Kirschgatterer, A et al, Cardiac tamponade following acupuncture. Chest 2000;117(5):1510-1.
(24) Lord RV, et al, False aneurysm of the popliteal artery complicating acupuncture. Aust NZ J Surg; 1996; 66(9);645-7
(25) Odsberg A, Schill U, Haker E. Acupuncture treatment side effects and complications reported by Swedish physiotherapists. Complementary Ther Med 2001;9(1)17-20.
(26) Kelsey JH. Pneumothorax following acupuncture is a generally recognised complication seen by many emergency physicians. J Emerg Med 1998;16(2)224-5.
(27) Bensoussan A and Myers, SP (1996). Towards a safer choice: the practice of traditional Chinese medicine in Australia, Faculty of Health, University of Western Sydney, McArthur.
(28) MacPherson H (1999).'Fatal and adverse events from acupuncture: Allegation, evidence and the implications', Journal of Alternative and Complementary Medicine (USA),5,1,47-56.
(29) Lu GD, Needham J. Celestial Lancets: a history and rationale of acupuncture and moxa. Cambridge University Press; 1980.
(30) Chinese Acupuncture and Moxibustion, Beijing Foreign Languages Press 1987.
(31) Choo DC, Yue G. Acute intracranial haemorrhage caused by acupuncture. Headache 2000; 40(5):397-8.
(32) Wang, Qi Cai (1983) Journal of Traditional Chinese Medicine, 1,25-26.
(33) White A, Hayhoe S. et al. Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. BMJ 2001; 323(7311): 485-6.
(34) McPherson H, Thomas K, et al. The York acupuncture safety study: prospective survey of 34 000 treatments by traditional acupuncturists. BMJ 2001; 323(7311): 486-7.
(35) Zhang Jing Yue, Lei Jing Tu Yi (1624 AD).
(36) Jiang Xi Zhong Yi Yao; (1):39.1981.
(37) Hasegawa J, Noguchi N, Yamasaki J et al. Delayed cardiac tamponade and hemothorax induced by an acupuncture needle. Cardiology 1991; 78(1)58-63.
(38) Cheng TO. Pericardial effusion from self-inserted needle in the heart. Eur Heart 1991; 12(8):958.
(39) Kataoka H. Cardiac tamponade caused by penetration of an acupuncture needle into the right ventricle. J Thorac Cardiovasc Surg 1997; 114(4):674-6.
(40) Schiff AF. A fatality due to acupuncture. Med Times (Lond) 1965; 93:630-1.
(41) Stark P, Midline Sternal Foramen: CT demonstration. J Comput Assist Tomogr 1985; 9(3):489-90.
(42) Schratter M, Bijack M, Nissel H, Gruber I et al. (The foramen sternale: a minor anomaly--great relevance). Rofo Fortschr Geb Rontgenst Neuen Bildgeb Verfahr 1997; 166(1):69-71.
(43) Gray's Anatomy; p 71,86,91.
(44) Nieda S, Abe T, et al. Case of a cardiac injury resulting from acupuncture, Kyobu Geka 1973; 26(12):881-3.
(45) McCaffrey T V. Rhinologic Diagnosis and Treatment. Thieme Medical Publishers Inc; 1997; p297.
(46) Deadman, P. Al-Khafaji, M. Baker, K. A Manual of Acupuncture, Journal of Chinese Medicine Publications, 2002.
Alicia Grant, MCSP, MAACP, MBAcC qualified as a physiotherapist at Sydney University and as an acupuncturist at Shanghai University of TCM, having also studied at Nanjing College of TCM, and Zhejiang TCM College Hospital in Hangzhou and in Hong Kong. She has practised acupuncture in South Africa and England for 25 years, is a tutor for the Acupuncture Association of Chartered Physiotherapists, and a director of Xinglin Postgraduate College of TCM in London. Professor B.Y. Ma, MD, MA, FRSM qualified as a doctor of medicine from Shanghai Medical University, China, in 1967. In 1978-81 he conducted research at the China Academy of TCM, then lectured at Shanghai Medical University and later was appointed as full professor and onto the Academic Board of the University. He collaborated with Dr. Joseph Needham on Science and Civilisation in China. Since 1995 he has practised and taught Chinese Medicine in London and he is now Principal of Xinglin Postgraduate College of TCM (U.K.) and a Fellow of the Royal Society of Medicine. He has published 10 books, including the well-known "A History of Medicine In Chinese Culture".
Safety is an important area of both public and medical concern. Following the vigorous growth of acupuncture in the west, more attention has been paid to recent reviews of adverse events. This does not need to surprise us; as far back as the Tang dynasty in China a famous author Wang Tao wrote a book called Wai Tai Mi Yao (A Medical Selection from the Secret Collection of the Royal Library). One sentence reads "Needles can kill people but cannot save dead peoples' lives". Later many scholars criticised this sentence because Wang Tao was a director of the Royal Library and not an acupuncturist. In fact it was not his 'invention'--it is a quote from the Ling Shu (chapter 60). This sentence was intended to warn practitioners to be careful to use needles safely and to learn TCM theory and technique in its entirety--it does not mean acupuncture is dangerous or useless.
However, there are some acupuncture points which are difficult and potentially dangerous to needle if one does not have a good technique. In the past, textbooks had no special chapter listing such points. Only two relatively modern books, each called "The Prevention and Treatment of Acupuncture Accidents", published in Chinese in 1988 and 1996, contain one chapter on the acupoints in ancient Chinese acupuncture books that some doctors regarded as requiring special caution. Our paper aims to explain clearly how to use these points safely. A knowledge of anatomy and pathology is essential. Good technique includes the exact angle and accurate depth of insertion. This can avoid many accidents.
From the anatomical viewpoint
In general a dangerous acupoint means that it is near important organs, nerves or arteries.
The head and face area
* Jingming BL-1 is near the ophthalmic and angular arteries and veins. With the eye closed the patient is asked to look laterally away from the side being needled, the eyeball is gently rolled aside and held with one hand and the needle inserted 0.3-0.5 cun perpendicularly along the orbital wall. No manipulation is performed.
* Chengqi ST-1 has branches of the infra-orbital and ophthalmic arteries and veins. Insertion is perpendicular, 0.3-0.5 cun along the infra-orbital ridge, and before insertion the patient is asked to look upwards and the eyeball is gently pressed upwards with a finger of the practitioner's other hand. The extra point Qiuhou (M-HN-8) is often used in preference. No manipulation is performed.
* Tinghui GB-2, Ermen SJ-21 and Tinggong SI-19 are near the auricular branches of the superficial temporal artery and vein. Palpate to feel the pulse so that it may be avoided, and needle to a depth of 0.3-0.5 cun.
* Some acupoints are near the medulla oblongata, e.g. Fengchi GB-20, Fengfu DU-16 and Yamen DU-15. At Fengchi GB-20 insertion should be perpendicularly 0.5-1.0 cun towards the tip of the nose. For the other two potentially dangerous points, insertion is perpendicular to the same depth. Deeper insertion could cause loss of consciousness and the needle, if angled towards one side, may injure the vertebral artery, causing headache and dizziness.
The neck
* Renying ST-9 lies very close to the carotid body and the carotid sinus. Interference with the former will affect respiration and with the latter cause a lowering of blood pressure which may lead to loss of consciousness. Insertion should be perpendicular to a depth of 0.2-0.4 cun.
* Tianrong SI-17 is close to the common carotid artery, which should be palpated and pressed aside. Insertion is perpendicular 0.3-0.5 cun.
* Tiantu REN-22 lies in front of the trachea and the needle is first inserted perpendicularly in the middle of the suprasternal fossa 0.2-0.4 cun. If the trachea were perforated it would produce a strong cough but not a pneumothorax. The needle may then be directed downwards along the posterior aspect of the sternum to a depth of 0.5-1.0 cun. If it should be angled sideways however, it could touch either the lung, resulting in a pneumothorax, or the aorta, producing haemoptysis with possible fatal consequences.
The chest
The lung in a thin person lies 10-20mm under the skin and there is danger of pneumothorax if the needle punctures the lung or pleural cavity. There are 90 incidents of this in the literature. The following points need special care because if the angle and depth are not correct the lung may be punctured.
* Jianjing GB-21. On the anterior aspect of the chest (at the mid-clavicular line) the pleural cavity extends down to the 8th intercostal space, and the upper lobe of the lung rises into the supra-clavicular fossa on inspiration. Although Jianjing GB-21 is usually needled perpendicularly to a depth of 0.3-0.5 cun, the authors prefer to pick up the trapezius muscle and insert the needle obliquely, then release the muscle, especially with emaciated patients.
* Quepen ST-12 and the adjacent extra point Jingbi (M-HN-41) (1) lie near the lung and are needled obliquely and posteriorly to a depth of 0.2-0.4 cun.
* Zhongfu LU-1 and Yunmen LU-2 lie just outside the lung but oblique insertion towards the lateral aspect of the chest is recommended to a depth of 0.5-0.8 cun.
* Tianchi P-1 is inserted obliquely only 0.2-0.4 cun.
* Riyue GB-24 is inserted obliquely 0.3-0.5 cun.
* Points Bulang KID-22 to Shufu KID-27, Shidou SP-17 to Zhourong SP-20 and Qihu ST-13 to Rugen ST-18 should be needled obliquely laterally to a depth of 0.3-0.5 cun.
* On the axillary line, laterally, the pleural cavity extends down to the 10th intercostal space. All points over this area should be needled obliquely to a depth of 0.3-0.5 cun, for example Dabao SP-21, Yuanye GB-22 and Zhejin GB-23.
The back
* On the posterior chest (back), under the thoracic spine, the pleural cavity extends to the twelfth rib at the lateral border of the erector spinae muscles, and this includes acupoints on both Bladder channel lines, namely Dazhu BL-11 to Weishu BL-21 and Fufen BL-41 to Weicang BL-50, which should be needled obliquely 0.3-0.5 cun. Similar care needs to be taken with acupoints Sanjiaoshu BL-22 to Shenshu BL-23 and Huangmen BL-51 to Zhishi BL-52 as these lie over the kidney area of the back.
* On the Small and Large Intestine channels, Jianwaishu SI-14, Jianzhongshu SI-15 and Jugu L.I.-16 lie over the lung and should therefore be needled obliquely to a depth of 0.3-0.6 cun.
The abdomen
In general, points on the abdomen are safe when not needled more than 0.5-0.8 cun deep. When the urinary bladder is full, deep needling at points Qugu REN-2 and Zhongji REN-3, and even Guanyuan REN-4, Shuidao ST-28, Guilai ST-29, Henggu KID-11, Dahe KID-12 and Qixue KID-13 may penetrate the bladder causing risk of infection. Wherever possible the patient should be asked to empty the bladder before needling. In cases of urinary retention scrupulous clean needle technique should be observed.
Infants
The top of the head should not be needled before the anterior fontanelle has closed (at up to 2 years old).
Blood vessels
It is advisable to palpate before needling to avoid certain blood vessels e.g. the radial artery at the wrist at Taiyuan LU-9, the dorsal pedal artery at the foot at Chongyang ST-42 (Chongyang), the superficial temporal artery at the ear at Tinghui GB-2, Ermen SJ-21 and Tinggong SI-19, the carotid artery at the neck at Renying ST-9 and the angular artery near the eye at Jingming BL-1. Also, when needling Jiquan HE-1 the axillary artery should first be palpated to avoid puncturing it. Insertion is perpendicular, 0.5-1.0 cun.
Anatomical aberrations
* Sternum: 5-8% of people in the western world have a sternal foramen, which may lie beneath the point Shanzhong (Tanzhong) REN-17. This does not show on X-ray but only on a CT scan, nor is it palpable as it is covered by a thin layer of membrane. Penetration through the sternal foramen may lead to a cardiac tamponade; seven instances have been recorded, including one fatal case in Norway. The needling depth for Shanzhong REN-17 should be no greater than 2 cm using horizontal (transverse) needling technique.
* Blood vessels: when palpating for the radial artery before needling Taiyuan LU-9, it may be found to be absent in a small minority of subjects. This is usually due to an anatomical aberration whereby the radial artery has bifurcated and the larger branch is then palpable between Lieque LU-7 and Yangxi L.I.-5. In TCM this is called "fan guan mai".
From a physiological viewpoint
* Pregnancy: Do not needle Sanyinjiao SP-6, Hegu L.I.-4 and Kunlun BL-60 at any stage of pregnancy unless the patient is overdue and the purpose is to induce labour. Zhiyin BL-67 should also not be needled during pregnancy unless you want to turn a foetal breech position at 32+ weeks.
In the Lei Jing Tu Yi (by the Ming Dynasty author Zhang Jing Yue) it was mentioned that Jianjing GB-21 should not be used during pregnancy, but is indicated for difficult labour. In 1981 an article in the journal Jiang Xi Zhong Yi Yac (2) reported that Jianjing GB-21 was very successful for preventing vomiting, including morning sickness--using only that single point. In our experience Jianjing GB-21 is effective for morning sickness but we would only recommend that it be used by an experienced acupuncturist when other methods have failed.
During the first 3 months of pregnancy do not needle points on the lower back such as Baliao (Shangliao BL-31 to Xialiao BL-34), and avoid using the auricular point Uterus (Zigong). After the third month do not needle points on the lower back or abdomen, such as Qugu REN-2, Zhongji REN-3 and Tianshu ST-25, and in addition after the fifth month avoid points Xiawan REN-10 to Zhongwan REN-12, although the latter may be needled, with shallow insertion and no manipulation, for stomach pain.
In Chinese textbooks since the 1980s it has been emphasised that Sanyinjiao SP-6, Hegu L.I.-4, Kunlun BL-60, Jianjing GB-21, Qugu REN-2, Zhongji REN-3 and auricular point Uterus, which are all contraindicated in pregnancy, should also be avoided during menstruation unless one is actually treating an abnormal menstrual condition.
* Weak, debilitated, hungry, thirsty or stressed patients have an increased tendency to faint. Allow them to rest, eat or drink first. Avoid using strong points such as Fengchi GB-20, Quchi L.I.-11, Hegu L.I.-4 and Zusanli ST-36 and avoid manipulation of the needle.
Any patient may faint in response to needling. When inserting needles the practitioner should observe the patient's face for tell-tale signs of pallor or sweating and all patients should be asked to report if they feel nauseous or dizzy. All patients are preferably treated on a treatment couch, lying or supported in a sitting position, both because they will be less likely to faint when supine and because the first action in case of fainting must be to remove the needles, and this can be difficult if they have slumped to the floor from a chair. They may also injure themselves falling. If faintness is reported or observed, the top of the treatment couch can be quickly lowered, increasing circulation to the head.
From a pathological viewpoint
* Bleeding tendency: this may occur with patients on warfarin or else on long-term cortisone treatment which thins the skin. Haemophilia is a total contraindication to acupuncture. As far as cortisone is concerned, in our experience, injections of a cortico-steroids into a joint will render acupuncture of that joint ineffectual for several weeks
* Scrupulous clean needle technique should be observed when needling points in the potentially dangerous triangle formed by Yintang (M-HN-3) and bilateral Dicang ST-4, as well as at Jingming BL-1, especially when treating facial skin infections such as acne. If the posterior wall of the frontal sinus is infected, infections of the central nervous system can result. This invasion may occur through direct invasion of venous channels and can spread to the skull by septic thrombophlebitis via the valveless veins of Brechet and can be life-threatening. In the area of Jingming BL-1 veins link to the cerebral veins. In western medicine the triangular area bordered by the middle of the eyebrows and the corners of the mouth--approximating to Yintang (M-HN-3) and Dicang ST-4--is regarded as especially susceptible to the introduction of infection via the veins.
* Enlarged organs: the liver, spleen, gall bladder, kidney and heart may all be enlarged due to disease, and all practitioners should have sufficient training in palpation to determine if this is so. When the liver or spleen are enlarged, take care with Jiuwei REN-15, Juque REN-14, Jingmen GB-25, Qimen LIV-14, Burong ST-19, Chengman ST-20 and Liangmen ST-21, which in this case should be punctured obliquely 0.3-0.5 cun. The kidney, if not greatly enlarged, will not be endangered by needling nearby points at a correct depth. If greatly enlarged, the patient's pathology will reflect this, and extreme caution should be exercised with local and adjacent needling.
* Epidemic disease: here it is the acupuncturist who needs to take care not to contract the patient's disease, e.g HIV or hepatitis B and C, by accidentally pricking themselves when removing the needles.
* Patients with pacemakers may not be given electro-acupuncture to the chest area.
* The following points may cause faintness in some people: Zhongzhu SJ-3, Waiguan SJ-5, Hegu L.I.-4, Quchi L.I.-11, Shousanli L.I.-10, Jianyu L.I.-15, Renying ST-9, Tianzong SI-11, Tianjing SI-13, Jianwaishu SI-14, Fengchi GB-20, Jianjing GB-21, Yanglingquan GB-34 and the auricular point adrenal. This is usually because they have a strong sensation or are particularly sensitive.
Causes of risk
From consideration of the above guidelines and from analysing reports of accidents with acupuncture, we can define the following main risk factors:
* inadequate training in acupuncture
* limited knowledge of anatomy or of certain physiological or pathological conditions
* failure to check for abnormal anatomy
* poor needling technique (depth and angle or stimulating too strongly)
* inadequate knowledge of records in ancient books or recent articles
* not paying attention to the patients' condition when they arrive
Safety can be guaranteed
The principle is to understand and remember why a point can be dangerous; every risk can be avoided if due care is taken. There is no need to be apprehensive: the British Acupuncture Council recently surveyed 34,407 treatments for adverse effects (3). There was an underlying serious adverse effect rate of between 0 and 1.1 per 10,000 treatments. A total of 43 minor adverse effects were reported, a rate of 1.3 per 1,000. A survey by Exeter University of 31,822 treatments by members of BMAS (British Medical Acupuncture Society) and the AACP (Acupuncture Association of Chartered Physiotherapists) also resulted in 43 minor adverse effects (4). Among the 43 adverse effects reported by each, most complaints were of a few common short-term symptoms that usually automatically disappeared, some of which are really regarded by acupuncturists as positive, such as a feeling of relaxation (11% of the 43) and feeling energised (6.6%). However even if acupuncture is so demonstrably safe we still need to be cautious for the patients' benefit and should remember that unexpected accidents have occurred. By avoidance of the risk factors, safety can be guaranteed.
Regarding needling technique, we would like to emphasise the following:
* Check that the needles are not in close proximity to organs or arteries.
* Consider the patient's build with regard to depth of needling. It is noted in the Huang Di Nei Jing (Yellow Emeror's Classic of Internal Medicine) that the recommended depth of insertion is for a patient of average build. All cun measurements refer of course to the patient's cun, not the acupuncturist's, who should check their hands against the patient's.
* If it is possible for the needle to touch a bone at a special point, e.g. Shanzhong REN-17 but it has not done so at the normal recommended anatomical depth, do not insert deeper: this is how the cardiac tamponade accident occurred in Norway. This also applies to Tianzong SI-11 as the scapula can also have a foramen.
* If the skin is lifted on insertion of the needle, penetration of the organ can be avoided.
* On the chest and back over the lung the angle of insertion is oblique or horizontal. The tip of the needle is usually directed obliquely towards the midline on the urinary bladder channel and obliquely and laterally on all other channel points passing over the trunk.
* When needling points around the eye, the patient is asked to look in the opposite direction to the point being needled and the practitioner gently holds the eyeball in that position while carefully inserting the needle. The needle is not retained for very long.
* Points near arteries should be palpated to ascertain the exact position of the artery and one finger should press against the artery while the other hand inserts the needle. Following the above techniques will ensure that your practice will be safe and effective.
Notes
(1) Jingbi M-HN-41 is located 1 cun superior to the junction of the medial third and lateral two thirds of the clavicle, at the posterior borer of the sternocleidomastoideus.
(2) Jiang Xi Zhong Yi Yac (1) 39:1981.
(3) MacPherson H. et al., British Medical Journal, 2001, 323:486-487.
(4) White A, Hayhoe S. et al. British Medical Journal 2001,323:485-6.
Source texts
(1) Huang Di Nei Jing, Ling Su, People's Health Press, 1963.
(2) Wang Tao, Wai Tai Mi Yao, People's Health Press, 1955.
(3) Huangfu Mi, Zheng Jiu Jia Yi Jing, People's Health Press, 1956.
(4) Sun Simiao, Bei Ji Qian Jin Yao Fang & Gian Jin Yi Fang, People's Health Press, 1955.
(5) Wang Weiyi, Tong Ren Shu Xue Zhen Jiu Tu Jing, People's Health Press, 1955.
(6) Wang Zhizhong, Zhen Jiu Zi Shen Jing, Shanghai Science & Technology Press, 1959.
(7) Xu Feng, Zhen Jiu Da Quan, People's Health Press, 1958.
(8) Gao Wu, Zhen Jiu Ju Ying, Shanghai Science & Technology Press, 1961.
(9) Yang Jizhou, Zhen Jiu Da Chen, People's Health Press, 1983.
(10) Wu Qian, Yi Zhong Jing Jian, People's Health Press, 1957.
(11) Yang Jiasan et al, Shu Xue Xue, Shanghai Science & Technology, 1984.
(12) Zhen Jiu Xue, People's Health Press, 1993.
(13) Zhang Ye et al, Shi Yong Ling ChuangZhen Jiu Xue, Shanghai Medical University Press, 1998.
(14) Zhang Ren et el, Zhen Jiu Yi Wai Yu Fang Ji Chu Li, Shanghai Science & Technology, Press, 1988.
(15) Wan Xiuying et al, Zhen Jiu Yi Wai Ji Fang Zi, Shandong Science & Technology Press, 1996.
(16) Lewith, G T, MacPherson, H . Reporting Adverse Events Following Acupuncture, Physiotherapy, 2001; 87.1.
(17) Peuker, E T, 'The need for practical courses in anatomy for acupuncturists'. FACT 2: 194. (1997).
(18) Peuker, E T, Fischer G, Filler T J, 'Facial vein terminating in the superficial temporal vein. (A potential risk for acupuncture in the face).'
(19) Ernst E, White AR editors, Acupuncture--a scientific appraisal. London: Butterworth-Heinemann, 1999; p.128-52.
(20) Halvorsen T B, Anda, S S, Naess, A B and Levang, O W. 'Fatal cardiac tamponade after acupuncture through congenital sternal foramen', Lancet,1995; 345, 1175.
(21) Ernst E, White A . 'Life-threatening adverse reactions after acupuncture? A systematic review'. Pain, 1997; 71: 123-126.
(22) House of Lords Select Committee 6th Report on Complementary and Alternative Medicine, London, The Stationary Office, 2000.
(23) Kirschgatterer, A et al, Cardiac tamponade following acupuncture. Chest 2000;117(5):1510-1.
(24) Lord RV, et al, False aneurysm of the popliteal artery complicating acupuncture. Aust NZ J Surg; 1996; 66(9);645-7
(25) Odsberg A, Schill U, Haker E. Acupuncture treatment side effects and complications reported by Swedish physiotherapists. Complementary Ther Med 2001;9(1)17-20.
(26) Kelsey JH. Pneumothorax following acupuncture is a generally recognised complication seen by many emergency physicians. J Emerg Med 1998;16(2)224-5.
(27) Bensoussan A and Myers, SP (1996). Towards a safer choice: the practice of traditional Chinese medicine in Australia, Faculty of Health, University of Western Sydney, McArthur.
(28) MacPherson H (1999).'Fatal and adverse events from acupuncture: Allegation, evidence and the implications', Journal of Alternative and Complementary Medicine (USA),5,1,47-56.
(29) Lu GD, Needham J. Celestial Lancets: a history and rationale of acupuncture and moxa. Cambridge University Press; 1980.
(30) Chinese Acupuncture and Moxibustion, Beijing Foreign Languages Press 1987.
(31) Choo DC, Yue G. Acute intracranial haemorrhage caused by acupuncture. Headache 2000; 40(5):397-8.
(32) Wang, Qi Cai (1983) Journal of Traditional Chinese Medicine, 1,25-26.
(33) White A, Hayhoe S. et al. Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. BMJ 2001; 323(7311): 485-6.
(34) McPherson H, Thomas K, et al. The York acupuncture safety study: prospective survey of 34 000 treatments by traditional acupuncturists. BMJ 2001; 323(7311): 486-7.
(35) Zhang Jing Yue, Lei Jing Tu Yi (1624 AD).
(36) Jiang Xi Zhong Yi Yao; (1):39.1981.
(37) Hasegawa J, Noguchi N, Yamasaki J et al. Delayed cardiac tamponade and hemothorax induced by an acupuncture needle. Cardiology 1991; 78(1)58-63.
(38) Cheng TO. Pericardial effusion from self-inserted needle in the heart. Eur Heart 1991; 12(8):958.
(39) Kataoka H. Cardiac tamponade caused by penetration of an acupuncture needle into the right ventricle. J Thorac Cardiovasc Surg 1997; 114(4):674-6.
(40) Schiff AF. A fatality due to acupuncture. Med Times (Lond) 1965; 93:630-1.
(41) Stark P, Midline Sternal Foramen: CT demonstration. J Comput Assist Tomogr 1985; 9(3):489-90.
(42) Schratter M, Bijack M, Nissel H, Gruber I et al. (The foramen sternale: a minor anomaly--great relevance). Rofo Fortschr Geb Rontgenst Neuen Bildgeb Verfahr 1997; 166(1):69-71.
(43) Gray's Anatomy; p 71,86,91.
(44) Nieda S, Abe T, et al. Case of a cardiac injury resulting from acupuncture, Kyobu Geka 1973; 26(12):881-3.
(45) McCaffrey T V. Rhinologic Diagnosis and Treatment. Thieme Medical Publishers Inc; 1997; p297.
(46) Deadman, P. Al-Khafaji, M. Baker, K. A Manual of Acupuncture, Journal of Chinese Medicine Publications, 2002.
Alicia Grant, MCSP, MAACP, MBAcC qualified as a physiotherapist at Sydney University and as an acupuncturist at Shanghai University of TCM, having also studied at Nanjing College of TCM, and Zhejiang TCM College Hospital in Hangzhou and in Hong Kong. She has practised acupuncture in South Africa and England for 25 years, is a tutor for the Acupuncture Association of Chartered Physiotherapists, and a director of Xinglin Postgraduate College of TCM in London. Professor B.Y. Ma, MD, MA, FRSM qualified as a doctor of medicine from Shanghai Medical University, China, in 1967. In 1978-81 he conducted research at the China Academy of TCM, then lectured at Shanghai Medical University and later was appointed as full professor and onto the Academic Board of the University. He collaborated with Dr. Joseph Needham on Science and Civilisation in China. Since 1995 he has practised and taught Chinese Medicine in London and he is now Principal of Xinglin Postgraduate College of TCM (U.K.) and a Fellow of the Royal Society of Medicine. He has published 10 books, including the well-known "A History of Medicine In Chinese Culture".
The application of acupuncture in place of hormone therapy.
By: Cheng, Lihong
The author of this article recently spent two years in clinical practice in Germany using acupuncture to replace steroids in the treatment of a wide range of diseases. To summarise his research he chose five representative cases, four of whom were able to stop steroids after completing a course of acupuncture. i. Chronic colitis. A 65 year old male patient presented with abdominal pain and diarrhoea of 13 years duration, passing watery, bloody stools 2-12 times daily. His condition worsened with stress and was only relieved by cortisone, but recurred on cessation of the drug. lie was diagnosed with Liver fire, with the Spleen failing to transform and transport, and given Baihui DU-20, Zhongwan REN-12, Tianshu ST-25, Qihai REN-6, Guanyuan REN-4, Zusanli ST-36 and Yinlingquan SP-9 with even method, and Taichong LIV-3 with dispersing method. All needles were retained for 30 minutes. Ear seeds were applied at ear shenmen, liver, spleen, lower rectum and large intestine, and pressed 3 times daily. After five treatments given twice weekly the cortisone was halved and after 10 treatments the patient was cured and the medication stopped. There was no recurrence on follow-up one year later. ii. Chronic migraine. A 52 year old woman reported chronic right-sided migraine following menopause, accompanied by nausea, vomiting and photosensitivity. Painkillers and steroids controlled the symptoms only. She was diagnosed with stirring of Liver wind and given Taiyang M-HN-9, Sizhukong, Shuaigu GB-8, Hanyan GB-4 and Xuanlu GB-5 on the right side, and Fengchi GB-20, Hegu L.I.-4 and Taichong LIV-3 bilaterally. The needles were retained for 30 minutes with dispersing method and given twice weekly for 15 weeks. iii. Rheumatoid arthritis. A 59 year old woman suffered rheumatoid arthritis in the knee joints for nine years, in spite of taking cortisone. Her symptoms improved on movement and worsened on wet days. She was diagnosed with obstruction of the channels by wind, cold and damp and needled with even method on Xiyan MN-LE-16, Zusanli ST-36, Xuehai SP-10, Liangqiu ST-34 and Ashi points. The needles were retained for 30 minutes and given twice weekly for 10 treatments. On her fifth visit a change in the weather worsened her symptoms. She was then given blood-letting cupping which made a dramatic improvement. The cortisone was stopped and by the eighth treatment she was cured. She was given two further treatments for consolidation. iv. Allergic asthma. A 25 year old man presented with asthma since birth. He was diagnosed with deficiency of Lung qi and poor constitutional qi, and was needled with even method on Feishu BL-13, Gaohuangshu BL-43, Tiantu REN-22, Chize LU-5, Taiyuan LU-9, Lieque LU-7, Zusanli ST-36 and Taixi KID-3. The needles were retained for 30 minutes, after which cupping was performed on the first two points for 10 minutes. Treatment was given twice weekly for 10 sessions after which all symptoms were gone. He was then given five more weekly treatments for consolidation. v Phemigoid. A 29 year old woman contracted herpes when she was six months pregnant. It was controlled by 40mg per day of cortisone but one year later she was still suffering significant side-effects and was not cured. She was diagnosed with qi deficiency and wind-damp-heat invasion in the blood, and the following points were needled: Dazhui DU-14, Quchi L.I.-11 and Waiguan SJ-5 were dispersed, and Baihui DU-20, Hegu L.I.-4, Xuehai SP-10, Yinlingquan SP-9, Zusanli ST-36 and Sanyinjiao SP-6 were needled with even method. Treatment was given for 30 minutes twice weekly for 10 sessions. After a two week rest from treatment with no recurrence of symptoms she was given 10 further weekly treatments until the drug was reduced to 5mg per day. She remained symptom free. The author concludes that these cases show acupuncture's ability to regulate the psycho-neuro-immunology of the body, and that as it is without harmful side-effects, it is a good replacement for steroids.
The author of this article recently spent two years in clinical practice in Germany using acupuncture to replace steroids in the treatment of a wide range of diseases. To summarise his research he chose five representative cases, four of whom were able to stop steroids after completing a course of acupuncture. i. Chronic colitis. A 65 year old male patient presented with abdominal pain and diarrhoea of 13 years duration, passing watery, bloody stools 2-12 times daily. His condition worsened with stress and was only relieved by cortisone, but recurred on cessation of the drug. lie was diagnosed with Liver fire, with the Spleen failing to transform and transport, and given Baihui DU-20, Zhongwan REN-12, Tianshu ST-25, Qihai REN-6, Guanyuan REN-4, Zusanli ST-36 and Yinlingquan SP-9 with even method, and Taichong LIV-3 with dispersing method. All needles were retained for 30 minutes. Ear seeds were applied at ear shenmen, liver, spleen, lower rectum and large intestine, and pressed 3 times daily. After five treatments given twice weekly the cortisone was halved and after 10 treatments the patient was cured and the medication stopped. There was no recurrence on follow-up one year later. ii. Chronic migraine. A 52 year old woman reported chronic right-sided migraine following menopause, accompanied by nausea, vomiting and photosensitivity. Painkillers and steroids controlled the symptoms only. She was diagnosed with stirring of Liver wind and given Taiyang M-HN-9, Sizhukong, Shuaigu GB-8, Hanyan GB-4 and Xuanlu GB-5 on the right side, and Fengchi GB-20, Hegu L.I.-4 and Taichong LIV-3 bilaterally. The needles were retained for 30 minutes with dispersing method and given twice weekly for 15 weeks. iii. Rheumatoid arthritis. A 59 year old woman suffered rheumatoid arthritis in the knee joints for nine years, in spite of taking cortisone. Her symptoms improved on movement and worsened on wet days. She was diagnosed with obstruction of the channels by wind, cold and damp and needled with even method on Xiyan MN-LE-16, Zusanli ST-36, Xuehai SP-10, Liangqiu ST-34 and Ashi points. The needles were retained for 30 minutes and given twice weekly for 10 treatments. On her fifth visit a change in the weather worsened her symptoms. She was then given blood-letting cupping which made a dramatic improvement. The cortisone was stopped and by the eighth treatment she was cured. She was given two further treatments for consolidation. iv. Allergic asthma. A 25 year old man presented with asthma since birth. He was diagnosed with deficiency of Lung qi and poor constitutional qi, and was needled with even method on Feishu BL-13, Gaohuangshu BL-43, Tiantu REN-22, Chize LU-5, Taiyuan LU-9, Lieque LU-7, Zusanli ST-36 and Taixi KID-3. The needles were retained for 30 minutes, after which cupping was performed on the first two points for 10 minutes. Treatment was given twice weekly for 10 sessions after which all symptoms were gone. He was then given five more weekly treatments for consolidation. v Phemigoid. A 29 year old woman contracted herpes when she was six months pregnant. It was controlled by 40mg per day of cortisone but one year later she was still suffering significant side-effects and was not cured. She was diagnosed with qi deficiency and wind-damp-heat invasion in the blood, and the following points were needled: Dazhui DU-14, Quchi L.I.-11 and Waiguan SJ-5 were dispersed, and Baihui DU-20, Hegu L.I.-4, Xuehai SP-10, Yinlingquan SP-9, Zusanli ST-36 and Sanyinjiao SP-6 were needled with even method. Treatment was given for 30 minutes twice weekly for 10 sessions. After a two week rest from treatment with no recurrence of symptoms she was given 10 further weekly treatments until the drug was reduced to 5mg per day. She remained symptom free. The author concludes that these cases show acupuncture's ability to regulate the psycho-neuro-immunology of the body, and that as it is without harmful side-effects, it is a good replacement for steroids.
Tung's acupuncture--an introduction
By: McCann, Henry
Abstract
Tung lineage acupuncture represents an ancient divergent approach to acupuncture treatment that has survived to the present day. It is characterised by its unique set of non-channel points, simple needling techniques, ample use of bleeding therapy and extensive use of distal points.
The history and basic characteristics of Tung acupuncture, and a point and two case study examples are presented.
Keywords: Tung Ching Chang, Master Tung, Tung acupuncture, dao ma, dao yin, bleeding therapy
**********
There is a common misperception that Chinese medicine, including acupuncture, is a unified system that has been handed down in a grand unbroken lineage to the present day. In fact, Chinese medicine is a field that is extraordinarily vast, representing numerous heterogeneous and even conflicting theories and treatment modalities. The seemingly homogenous model of Chinese medicine known as "Traditional Chinese Medicine" (TCM) is the product of a twentieth century synthesis of many approaches to Chinese medicine that was created in response to many factors, including the near decline of Chinese medicine under the Kuomingtang government, the needs of administering inexpensive medical care to a vast Chinese population after the Communist revolution, and the People's Republic of China's (PRC) desire to have TCM mimic modern western scientific models of research design and education (1).
Throughout Chinese history, physicians learned medicine in a wide variety of settings and through many avenues. Some physicians, including many well-respected and famous ones, were self-taught through written texts. At points in China's history various imperial academies existed for training imperial, literate and scholarly physicians. Yet other physicians trained in family lineages of medicine, which, like martial arts lineage traditions, were handed down from father to child, guarded as family treasures and rarely disclosed to outsiders. One positive aspect of the creation of TCM was that some family lineages opened up to outsiders and were absorbed into this new synthesis of Chinese medicine. A downside of the creation of TCM, however, was that such family systems were sometimes taken out of the hands of lineage holders and entrusted to large university-style training programs.
The Tung (2) lineage of classical Chinese medicine is one such old family lineage that has survived into the present day, independent of the TCM movement. Tung's acupuncture is fairly well known in Taiwan, the final home of the last member of the Tung lineage to practise medicine, although it has only recently gained notoriety in the west. This article will serve as a general introduction to the history and unique aspects of Tung's family lineage.
Tung Ching Chang and the History of Tung Acupuncture (3)
The history of Tung's acupuncture is somewhat vague, a phenomenon not uncharacteristic of family systems. According to its own stated history, Tung's lineage was a family system passed down from father to eldest son from the Han (206 BCE to 220 CE) dynasty. All documents related to Tung's acupuncture were lost during China's civil war in the 20th century and thus at this point it may be impossible to achieve a more detailed history.
The last descendant of the Tung family to practise acupuncture was the renowned Tung Ching Chang, known today as Master Tung. Master Tung was born in 1916 in Ping Du County, Shandong Province, Republic of China (4). As a young man Master Tung assisted his father in treating local patients with all sorts of ailments. Due to the chaotic influence of China's warlords on his hometown, Tung was unable to receive a formal school-based education. The Japanese invasion of China during World War II further disrupted life for the Chinese, and Master Tung, a patriotic Shandong native, entered the Nationalist Army to fight the Japanese.
After China's victory over Japan in 1945, the then 29-year-old soldier returned to Ping Du with the intention of opening a private practice. However, by that time the Communists under Mao Zedong had already engaged the depleted and exhausted Nationalist Army in a widespread civil war. During this period Ping Du County was occupied several times by Maoist soldiers and a Russian style collective community was established in most of Shandong Province. Tung, believing it would be impossible to return to a stable life in his beloved Shandong, vowed to work towards the elimination of Maoist Communists in China and returned to military service with the Nationalist Army.
Mao Zedong's forces eventually succeeded in defeating the Nationalists under President Chiang Kai Shek. In 1949 President Chiang, along with many of his followers, including Master Tung, retreated to Taiwan Province and established the current Republic of China (ROC). While in the army, Master Tung treated tens of thousands of his fellow soldiers. In the early 1960s he retired from military service and opened his first acupuncture clinic for the general public in Taipei, where all persons rich and poor could benefit from his unique treatment style. Over his years of practice he was estimated to have performed over 300,000 treatments. Many patients came as referrals from other Chinese medical clinics, and found relief from their ailments only when treated with Tung's family method. Besides the regular patients in his Taipei clinic, Master Tung was known for treating many famous persons including the Defense Minister of the ROC. Tung was especially renowned for his successful treatment of President Lon Nol of Cambodia following a stroke.
After many years of residence in Taiwan, Master Tung was touched and influenced by President Chiang's Cultural Renaissance Movement [TEXT NOT REPRODUCIBLE IN ASCII]. This was established in 1966 to promote Chinese culture as a direct response to what was perceived as its wholesale destruction in mainland China as a result of Mao's Cultural Revolution. In order to preserve Tung's acupuncture lineage for the benefit of future generations, Master Tung decided to train students. According to his own instructions, upon the master's death in 1975, the names of his 73 disciples were carved on the stone epitaph at his burial site. Master Tung did marry and has a son who is not interested in learning medicine. Tung's disciples however promised to teach his son acupuncture at any time in the future, should he change his mind.
Master Tung was a well-known and highly respected physician in Taiwan. However, when the ROC finally implemented regulation of Chinese medicine and acupuncture, Tung was denied a license, despite the fact that the Taiwanese government had previously promised him a special licensure to thank him for his prominent service to his country. Tung perceived this as a terrible betrayal by the government and it was a humiliating defeat for this proud Shandong native. This rejection had a devastating effect on Master Tung who closed his practice and died from stomach cancer only a short time later.
Before his death, Master Tung was urged by his students to agree to the publication of a book containing reliable information about his family's extra-point-based system. Two years prior to his death, he personally authorised and approved two such works. The original Chinese language edition was written with the help of his disciple Yuan Kuo Pen. At the same time Master Tung requested that his only Tibetan disciple, Dechen Palden (now Dr. Palden Carson), then a medical student at the National Taiwan University, translate and edit the Chinese manuscript into English. In 1988, the English language edition was rewritten by Dr. Carson and republished under the new title Tung's Orthodox Acupuncture.
Characteristics of Tung's acupuncture Tung's Points
The most prominent feature of Tung's acupuncture is the Tung family's set of points, which Master Tung termed "orthodox channel extra (curious) points" (5). While some of these points lie in approximately the same location as some of the conventional points of 14 channel acupuncture, the majority of Tung's points are in unique locations, and even when analogous to conventional points have different point groupings and functions.
The distribution of Tung's points covers the entire body although, unlike 14 channel acupuncture, they are arranged topographically by anatomical zonal concepts rather than by channel. For example, zone number one contains points located on the fingers, zone number two on the hand, and zone number three on the forearm (see Table 1 for a list of zones and number of points found in each zone). Each zone contains points that have a wide-ranging effect over many areas of the body. In fact, each zone can almost be viewed as an independent microsystem (such as ear or scalp systems).
The most commonly used points lie on the extremities and the head, and even though there are ample points on the ventral and dorsal trunk, they are very rarely needled. The fingers and palmar surface of the hand, and the toes and plantar aspect of the foot have a much greater distribution of points than in 14 channel acupuncture. Each point has a specific name and each is also sometimes referred to by a numerical system based on the zone where the point is found. For example, the first point on the fingers, Ta Chien (Da Jian [TEXT NOT REPRODUCIBLE IN ASCII]), is also designated 1.01, i.e. point number one located in zone number one.
Tung's points, instead of being associated with a conventional channel (for example Hegu L.I.-4 belongs to and acts on the arm yangming channel), are described as having a "reaction area" (6) that essentially describes the area of influence of that point or group of points. In some cases a reaction area corresponds to one of the zangfu and in other cases it represents an anatomical area. For example, some points used to treat post-stroke hemiplegia have the reaction area of the "extremities" (7). Certain points also have different reaction areas depending on the depth of needle insertion. Tung's point Ming Huang (8.12 [TEXT NOT REPRODUCIBLE IN ASCII]), located at the centre of the middle line of the medial aspect of the thigh, has a reaction area of the Kidney when needled superficially, the Liver when needled to a medium depth, and the Heart when needled deeply.
In general, Master Tung used his points on the head and hand to treat acute or more recent conditions, and needling these points most often achieves rapid and dramatic reduction of symptoms. Points on the leg, especially those proximal to the knees, are used to treat more chronic and complex conditions. This use of points in particular contrasts dramatically with TCM acupuncture, which utilises points on the thigh infrequently.
Characteristics of treatment and needle technique
Tung's acupuncture is characterised by the use of a minimal number of points in each treatment, usually no more than six. Master Tung favoured the use of large gauge needles (such as 0.40 mm, or 26 guage) and needled freehand, often times through clothing (8). There is a conspicuous lack of complex needle manipulation and there is no use of supplementation (bu fa) or drainage technique (xie fa). Needle depth is varied according to the condition, although Tung made ample use of deep needling (often touching the periosteum of underlying bone) and through-and-through needle techniques to connect multiple points with one needle.
Points are almost always needled distally and contralaterally to the site of disease or dysfunction, and points on the top of the body are used to treat the bottom and vice versa. For example, Tung's points on the plantar surface of the foot generally treat conditions of the head and brain/mind.
Points also treat diseases corresponding to the location of the point. For example, points on the forearm treat pain in the forearm, etc. Unlike conventional 14 channel acupuncture however, these points are not needled locally on the diseased side but rather on the healthy side of the body. Once needles are inserted they are retained for long periods of time, usually in excess of 30 or 45 minutes. Occasionally, throughout the treatment, needles are manipulated with even twirling to strengthen the therapeutic effect.
Point Selection and combination Dao yin needle technique [TEXT NOT REPRODUCIBLE IN ASCII]
One of the benefits of distal acupuncture point stimulation is that it frees up the diseased area for local stimulation (e.g., self-movement or massage). In the dao yin, or 'conducting qi', technique distal points are needled and then the patient is required to mobilise the diseased or painful area. For example, in cases of shoulder pain, point Tse Hua Chong (7.09 Si Hua Zhong [TEXT NOT REPRODUCIBLE IN ASCII]--similar in location to Tiaokou ST-38) is needled contralaterally to the painful side while the patient is asked to mobilise the painful shoulder. In cases where the patient is unable to move, the practitioner can move or manipulate the joint for the patient.
According to Chinese medicine, pain is the patient's subjective perception of stagnant qi and blood in an area. The dao yin needle technique is particularly effective in that it very strongly moves qi and blood in the channels through distal needling and moves qi locally through active physical movement or stimulation.
Dao ma needle technique [TEXT NOT REPRODUCIBLE IN ASCII]
The dao ma 'inverted horse' technique uses combinations of two or three points in a given area, most commonly arranged in a vertical line, to augment needle stimulation. These points are located near to each other, usually no more than two or three cun apart. On the hands and fingers however, these points are much closer together, usually less than one cun apart. In fact many of Tung's unique points are arranged in two or three point sets, meaning that these dao ma groups are always needled in combination rather than as single points.
Dao ma point groupings serve to increase needle stimulation in the treatment target area, thereby achieving more effective and immediate results when needling points distal to the area of disease.
Non-acupuncture therapies of Tung's acupuncture
Triangular needle bleeding therapy [TEXT NOT REPRODUCIBLE IN ASCII]
Bleeding therapy plays a major role in Tung's acupuncture, far more so than in 14 channel acupuncture. Master Tung believed that most chronic disease, painful conditions, and all fatal disease always involve stasis of qi and especially blood. Bleeding therapy in general strongly moves the blood, and the qi via the blood. Thus, bleeding therapy can be used to treat a wide variety of recalcitrant conditions.
In Tung's acupuncture, points over the entire body can be bled. Unlike in 14 channel acupuncture, Tung made frequent use of bleeding points on the trunk. Actually, the majority of Tung's points on both the dorsal and ventral trunk are never needled, only bled. While in Tung's acupuncture points are needled contralaterally to the side of pain or dysfunction, bleeding is typically done ipsilaterally.
Moxibustion and other miscellaneous therapies
The vast majority of treatment in Tung's lineage involves needling acupuncture points or bleeding therapy. Master Tung did, however, utilise other therapies when necessary. Moxibustion, while not performed as frequently as in 14 channel acupuncture, is used to warm and supplement points. For example, Tung's point Huo Fu Hai (3.07 [TEXT NOT REPRODUCBLE IN ASCII], located between the ulna and radius on the posterior forearm 8.5 cun proximal to the wrist joint) is stimulated with moxibustion to treat conditions related to anemia and general vacuity. Like many points treated with moxibustion, the application of moxa to this point is said to increase longevity. Master Tung preferred to have patients use moxibustion as a long-term daily home therapy rather than applying it as short-term treatment in his own clinic.
Master Tung also made use of cupping and scraping (gua sha) therapy as local treatments. Furthermore, while Tung was primarily an acupuncturist, he was well aware of the composition of classical herbal formulae and occasionally prescribed herbs in cases where he thought it was necessary. More commonly than using herbs however, Tung would prescribe simple dietary remedies for patients. A section on dietary recommendations for a variety of disorders is included in Tung's original Chinese language text (9). Thus, Master Tung was not only a talented acupuncturist, but also was an expert in all areas of Chinese medicine.
Classical Daoist (Taoist) therapies
While in the west it is commonly believed that Chinese medicine is synonymous with Daoist medicine, this is not necessarily the case. It is true that many advances in Chinese pharmacology were made by Daoist adepts, yet a great number of Daoist movements actually forbad their members from using herbal therapies or acupuncture in favour of purely religious methods of healing such as prayer, ritual petitions to Daoist deities, and the use of talismanic magic (fu zhou [TEXT NOT REPRODUCIBLE IN ASCII]) (10). Early texts of Chinese medicine, such as Sun Si Miao's Qian Jin Yao Fang, recognised the use of religious healing and included these therapies alongside herbal formulae or acupuncture protocols.
Master Tung was a devout practitioner of the Daoist religion. In his own clinic he occasionally wrote talismans for patients, to treat both physical ailments and social and psychological problems such as marital troubles. Master Tung's familiarity with these ancient shamanistic therapies demonstrates that he was well steeped in classical Chinese medicine before it was purged of therapies the government of the PRC deemed superfluous or superstitious.
Point example: Wu Hu (Five Tigers)
The points Wu Hu (1.27 [TEXT NOT REPRODUCIBLE IN ASCII]) are a commonly used dao ma set in Tung's acupuncture. They are a collection of five points evenly distributed along the radial border of the proximal phalanx of the thumb, located on the demarcation of the red and white skin. The Wu Hu points are associated with the reaction area of the Spleen, and according to Master Tung treat bony swellings, rheumatoid and osteo- arthritis, acute ankle pain, and other acute traumatic ligamentous injuries. Two or three of these points are needled simultaneously, contralaterally to the site of pain, while the patient then mobilises the affected area (an application of the dao yin needle technique combined with the dao ma needle technique).
The Wu Hu points treat conditions of both the upper and lower body. According to one of Tung's disciples, the more distal of the Wu Hu points treat conditions of the upper extremities, while the more proximal of the Wu Hu points treat conditions of the lower extremities (11). Generally, the Wu Hu points are needled perpendicularly with the tips of the needles touching the periosteum of the phalange.
[FIGURES 1-3 OMITTED]
Case study 1: ankle sprain
A 65-year-old patient presented to my office with an acute sprain of the left ankle. She had already been evaluated by her physician, and imaging tests showed no significant physical damage. She complained of pain around the entire ankle, which was quite swollen and hot to the touch. The only treatment she had received was a soft splint and the recommendation that she take analgesics as necessary.
In the office she was asked to sit and elevate her ankle and the soft cast was removed for comfort as well as to allow her to move the ankle slightly. The points for treatment were the three proximal points of the Wu Hu (1.27) set on the right thumb. The three points were needled to a depth of three to four millimetres, until the tip of the needle touched the periosteum of the phalanx, eliciting a heavy sensation. The patient was periodically asked to gently move the painful ankle and the needles were manipulated with a simple even twirling every 15 minutes. The needles were retained for 45 minutes and no other points were used during this treatment.
By the end of the treatment the patient reported a dramatic reduction in pain and could walk again with only a minimal limp. Furthermore by the end of the treatment there was barely any visible swelling of the ankle and on palpation the temperature of the skin had normalised to the same level as the healthy ankle.
Case study 2: spondylosis
An 80 year-old male presented with a main complaint of back pain. He had a diagnosis of spondylosis and fractured lumbar vertebrae, and presented with a severe kyphosis as well as a scoliosis (he had lost 12 centimetres in height in the last year alone). The pain began about four months prior to his first acupuncture treatment after he underwent chiropractic manipulation. The pain was worse in the morning when getting out of bed and after standing for any period of time, and walking was difficult. His tongue was pale and his pulse was deep and very weak. There were small spider naevi on his face near Chengqiang REN-24. In Chinese medicine terms he presented with a Kidney yang vacuity with local qi and blood stasis in the spine and lumbar area. In Tung's acupuncture the chin is associated with the Kidney and a dark colour or presence of spider naevi in this area shows a vacuity in the Kidney system, further corroborating the tongue and pulse findings.
It was impossible for this patient to lie down for treatment so he was treated sitting upright. The points used for treatment were Shui King (10.20 Shui Jin [TEXT NOT REPRODUCIBLE IN ASCII]), Shui T'ung (10.19 Shui Tong [TEXT NOT REPRODUCIBLE IN ASCII] ), Hou Chui (4.02 Hou Zhui [TEXT NOT REPRODUCIBLE IN ASCII]), Shou Ying (4.03 Shou Ying [TEXT NOT REPRODUCIBLE IN ASCII]), and Shen Kuan (7.18 Shen Guan [TEXT NOT REPRODUCIBLE IN ASCII]). Shui King and Shui T'ung are located on the face. Specifically, Shui T'ung is located 0.4 cun inferior to the corner of the mouth and Shui King is located 0.4 cun medial to Shui T'ung. These points have a reaction area of the Kidney and can be used to treat lumbar pain associated with Kidney vacuity (12). In this patient the points were needled with a 30 gauge 40 mm needle. The needle was inserted bilaterally into Shui King and then inserted through and through subcutaneously to Shui T'ung.
Shen Kuan is a major point in Tung's acupuncture for supplementing the Kidney and is located 1.5 cun inferior to the medial condyle of the tibia (the area of Yinlingquan SP-9) (13). For this treatment Shen Kuan was needled bilaterally with a 28 gauge 50mm needle to a depth of just under two cun. Hou Chui and Shou Ying are part of a dao ma group, and are needled together as a group more commonly than as single points. Hou Chui is located on the posterior arm, 2.5 cun proximal to the olecranon, and Shou Ying is located longitudinally two cun proximal to Hou Chui. As the name suggests, Hou Chui, Back Vertebra, is used to treat problems of the vertebrae. Both Hou Chui and Shou Ying have a reaction area of the spine and are indicated for spinal pain, prolapsed intervertebral disc, lumbar pain and nephritis (14). These two points were needled on the left arm only as the pain was worse on the right side. These two points were also needled with 28 gauge 50mm needles and inserted until the tips of the needles touched the humerus. In total only six needles were used per treatment.
After the first treatment the patient noticed that there was no longer any pain getting out of bed in the morning although there was some pain by the end of the day when he was tired. He was able to stand, however, for much longer periods of time without discomfort. After the second treatment he was able to stand and sit straighter than he had before and the pain relief lasted almost the entire week between treatments. Furthermore, the visible veins on his face were thinner and lighter in colour. To date the patient has had three treatments in all.
Conclusion
Tung's acupuncture represents a rare example of a traditional family lineage of Chinese medicine that has survived into the present day. The uniqueness of Tung's acupuncture challenges and expands knowledge of the basic tenets of acupuncture such as the location of points, their arrangement in channels and their major indications. Tung's approach to acupuncture and Chinese medicine therefore reminds practitioners that it is impossible to point to any one school of thought and practice and believe it is the sole inheritor of the vast ocean of Chinese medicine practised from the days of the Yellow Emperor.
Master Tung was a physician with exceptional generosity, bravery and foresight to teach his family's medical heritage to outsiders for the sake of continuing the lineage and benefiting patients with an exceptionally effective therapy. Perhaps this willingness to share previously 'secret' information will encourage other Chinese medical practitioners, who may still practise family lineages, to open their teachings to outsiders so that they may continue into the future and benefit many more patients than one practitioner alone can treat.
Acknowledgement
Special thanks to Dr. Palden Carson, M.D., president of the World Tung's Acupuncture Association, a personal disciple of Master Tung, and my teacher who has lead me into the wonderful practice of Tung's Orthodox Acupuncture. He was extraordinarily generous in providing information for this article as well as offering corrections and suggestions before publication.
Bibliography
Carson, P. (1988) Tung's Orthodox Acupuncture. Taipei: Lien Ho Press, Co.
Tung, CC. (1973) Tung Shih Chen Chiu Cheng Ching Ch'i Hsueh Hsueh. Taipei: Hsin Ya Publications Ltd.
Yang, WJ. (1999) Dong Shi Qi Xue Zhen Jiu Xue. Taipei: Chih Yuan Bookstore.
Notes
(1) For a more in-depth discussion of both the positive and negative aspects surrounding the creation of TCM see Fruehauf, Heiner. "Science, Politics, and the Making of TCM: Chinese Medicine in Crisis." Journal of Chinese Medicine 61; October 1999.
(2) Tung is the Wade-Giles Romanisation of the Chinese family name. In pinyin Romanisation (the system created by and used currently in the PRC and in most academic circles) the name is Romanised "Dong". Either way, the pronunciation is the same, with a "d" sound at the beginning. Master Tung was a very staunch anticommunist and thus resisted the use of anything related to the communist government of mainland China, including the pinyin system. When Master Tung was alive he himself preferred the spelling "Tung" to represent his name. Thus, in accord with the practice of the World Tung's Acupuncture Association, throughout this article Wade-Giles Romanisation will be used for his name. However in the years since Master Tung's passing, the pinyin system has gradually become the standard academic method of Romanising Chinese, even in Taiwan. Thus all other Chinese medical terms will be given in pinyin. Tung's point names will be given in Wade-Giles first and Pinyin second for those not familiar with the Wade-Giles system.
(3) Historical information was generously provided by Dr. Palden Carson.
(4) Master Tung was very proud of being a native of Shandong. On the cover of his book and on his business cards, Master Tung was listed as "Shandong Tung Ching Chang" (See Tung, 1973) and never referred to himself as either "Taiwanese" or "Mainland Chinese". This is in direct conflict with some texts now being published in Taiwan that claim Master Tung's acupuncture is a form of "Taiwanese acupuncture."
(5) In Chinese [TEXT NOT REPRODUCIBLE IN ASCII]. The term "curious" is the same word used to describe the Eight Extraordinary (Curious) Vessels and the Six Curious Bowels (Fu). (See Tung, 1973).
(6) The original term for "reaction area" in Master Tung's book is Shen Jing ([TEXT NOT REPRODUCIBLE IN ASCII]). This term is usually translated into English as "nerve".
(7) The point Chung Chiu Li (8.25 Zhong Jiu Li [TEXT NOT REPRODUCIBLE IN ASCII]), for example, has a reaction area of the Lung and Extremities. It is located on the median line of the lateral thigh, nine cun above the upper margin of the patella (or at the midpoint of the thigh).
(8) Of course, this directly contradicts standard clean needle technique protocols that acupuncturists are taught today. However, in ancient China (especially in the cold north such as in Shandong province) this was common practice.
(9) Tung, appendix pg. 15-18.
(10) Kohn, Livia. Daoism and Chinese Culture. Cambridge: Three Pines Press, 2001, pg. 75.
(11) Yang, pg. 26.
(12) Carson, pg. 199-200.
(13) Ibid., pg. 125.
(14) Ibid., pg. 62-63.
Henry McCann is a licensed acupuncturist, a licensed Doctor of Acupuncture, and a Diplomate in Oriental Medicine (NCCAOM). He graduated from Oberlin College in Ohio and the New England School of Acupuncture in Massachusetts, and was a Fulbright research fellow to the University of the Ryukyus in Okinawa, Japan. Henry serves on the New Jersey State Acupuncture Examining Board by gubernatorial appointment, and is a member and the New Jersey representative of the World Tung's Acupuncture Association. He can be reached at www.newjerseyacupuncture.com.
Table 1: Point
Distribution
in Tung's
Acupuncture
Zone Location Number of Points
1 Fingers 27
2 Palm and dorsal hand 11
3 Forearm 16
4 Upper Arm 17
5 Plantar aspect of foot 6
6 Dorsal foot 6
7 Leg/Calf 28
8 Thigh 32
9 Ear 8
10 Head 25
Note: There are also more than 160 additional points on the neck, and
both the dorsal and ventral trunk.
Abstract
Tung lineage acupuncture represents an ancient divergent approach to acupuncture treatment that has survived to the present day. It is characterised by its unique set of non-channel points, simple needling techniques, ample use of bleeding therapy and extensive use of distal points.
The history and basic characteristics of Tung acupuncture, and a point and two case study examples are presented.
Keywords: Tung Ching Chang, Master Tung, Tung acupuncture, dao ma, dao yin, bleeding therapy
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There is a common misperception that Chinese medicine, including acupuncture, is a unified system that has been handed down in a grand unbroken lineage to the present day. In fact, Chinese medicine is a field that is extraordinarily vast, representing numerous heterogeneous and even conflicting theories and treatment modalities. The seemingly homogenous model of Chinese medicine known as "Traditional Chinese Medicine" (TCM) is the product of a twentieth century synthesis of many approaches to Chinese medicine that was created in response to many factors, including the near decline of Chinese medicine under the Kuomingtang government, the needs of administering inexpensive medical care to a vast Chinese population after the Communist revolution, and the People's Republic of China's (PRC) desire to have TCM mimic modern western scientific models of research design and education (1).
Throughout Chinese history, physicians learned medicine in a wide variety of settings and through many avenues. Some physicians, including many well-respected and famous ones, were self-taught through written texts. At points in China's history various imperial academies existed for training imperial, literate and scholarly physicians. Yet other physicians trained in family lineages of medicine, which, like martial arts lineage traditions, were handed down from father to child, guarded as family treasures and rarely disclosed to outsiders. One positive aspect of the creation of TCM was that some family lineages opened up to outsiders and were absorbed into this new synthesis of Chinese medicine. A downside of the creation of TCM, however, was that such family systems were sometimes taken out of the hands of lineage holders and entrusted to large university-style training programs.
The Tung (2) lineage of classical Chinese medicine is one such old family lineage that has survived into the present day, independent of the TCM movement. Tung's acupuncture is fairly well known in Taiwan, the final home of the last member of the Tung lineage to practise medicine, although it has only recently gained notoriety in the west. This article will serve as a general introduction to the history and unique aspects of Tung's family lineage.
Tung Ching Chang and the History of Tung Acupuncture (3)
The history of Tung's acupuncture is somewhat vague, a phenomenon not uncharacteristic of family systems. According to its own stated history, Tung's lineage was a family system passed down from father to eldest son from the Han (206 BCE to 220 CE) dynasty. All documents related to Tung's acupuncture were lost during China's civil war in the 20th century and thus at this point it may be impossible to achieve a more detailed history.
The last descendant of the Tung family to practise acupuncture was the renowned Tung Ching Chang, known today as Master Tung. Master Tung was born in 1916 in Ping Du County, Shandong Province, Republic of China (4). As a young man Master Tung assisted his father in treating local patients with all sorts of ailments. Due to the chaotic influence of China's warlords on his hometown, Tung was unable to receive a formal school-based education. The Japanese invasion of China during World War II further disrupted life for the Chinese, and Master Tung, a patriotic Shandong native, entered the Nationalist Army to fight the Japanese.
After China's victory over Japan in 1945, the then 29-year-old soldier returned to Ping Du with the intention of opening a private practice. However, by that time the Communists under Mao Zedong had already engaged the depleted and exhausted Nationalist Army in a widespread civil war. During this period Ping Du County was occupied several times by Maoist soldiers and a Russian style collective community was established in most of Shandong Province. Tung, believing it would be impossible to return to a stable life in his beloved Shandong, vowed to work towards the elimination of Maoist Communists in China and returned to military service with the Nationalist Army.
Mao Zedong's forces eventually succeeded in defeating the Nationalists under President Chiang Kai Shek. In 1949 President Chiang, along with many of his followers, including Master Tung, retreated to Taiwan Province and established the current Republic of China (ROC). While in the army, Master Tung treated tens of thousands of his fellow soldiers. In the early 1960s he retired from military service and opened his first acupuncture clinic for the general public in Taipei, where all persons rich and poor could benefit from his unique treatment style. Over his years of practice he was estimated to have performed over 300,000 treatments. Many patients came as referrals from other Chinese medical clinics, and found relief from their ailments only when treated with Tung's family method. Besides the regular patients in his Taipei clinic, Master Tung was known for treating many famous persons including the Defense Minister of the ROC. Tung was especially renowned for his successful treatment of President Lon Nol of Cambodia following a stroke.
After many years of residence in Taiwan, Master Tung was touched and influenced by President Chiang's Cultural Renaissance Movement [TEXT NOT REPRODUCIBLE IN ASCII]. This was established in 1966 to promote Chinese culture as a direct response to what was perceived as its wholesale destruction in mainland China as a result of Mao's Cultural Revolution. In order to preserve Tung's acupuncture lineage for the benefit of future generations, Master Tung decided to train students. According to his own instructions, upon the master's death in 1975, the names of his 73 disciples were carved on the stone epitaph at his burial site. Master Tung did marry and has a son who is not interested in learning medicine. Tung's disciples however promised to teach his son acupuncture at any time in the future, should he change his mind.
Master Tung was a well-known and highly respected physician in Taiwan. However, when the ROC finally implemented regulation of Chinese medicine and acupuncture, Tung was denied a license, despite the fact that the Taiwanese government had previously promised him a special licensure to thank him for his prominent service to his country. Tung perceived this as a terrible betrayal by the government and it was a humiliating defeat for this proud Shandong native. This rejection had a devastating effect on Master Tung who closed his practice and died from stomach cancer only a short time later.
Before his death, Master Tung was urged by his students to agree to the publication of a book containing reliable information about his family's extra-point-based system. Two years prior to his death, he personally authorised and approved two such works. The original Chinese language edition was written with the help of his disciple Yuan Kuo Pen. At the same time Master Tung requested that his only Tibetan disciple, Dechen Palden (now Dr. Palden Carson), then a medical student at the National Taiwan University, translate and edit the Chinese manuscript into English. In 1988, the English language edition was rewritten by Dr. Carson and republished under the new title Tung's Orthodox Acupuncture.
Characteristics of Tung's acupuncture Tung's Points
The most prominent feature of Tung's acupuncture is the Tung family's set of points, which Master Tung termed "orthodox channel extra (curious) points" (5). While some of these points lie in approximately the same location as some of the conventional points of 14 channel acupuncture, the majority of Tung's points are in unique locations, and even when analogous to conventional points have different point groupings and functions.
The distribution of Tung's points covers the entire body although, unlike 14 channel acupuncture, they are arranged topographically by anatomical zonal concepts rather than by channel. For example, zone number one contains points located on the fingers, zone number two on the hand, and zone number three on the forearm (see Table 1 for a list of zones and number of points found in each zone). Each zone contains points that have a wide-ranging effect over many areas of the body. In fact, each zone can almost be viewed as an independent microsystem (such as ear or scalp systems).
The most commonly used points lie on the extremities and the head, and even though there are ample points on the ventral and dorsal trunk, they are very rarely needled. The fingers and palmar surface of the hand, and the toes and plantar aspect of the foot have a much greater distribution of points than in 14 channel acupuncture. Each point has a specific name and each is also sometimes referred to by a numerical system based on the zone where the point is found. For example, the first point on the fingers, Ta Chien (Da Jian [TEXT NOT REPRODUCIBLE IN ASCII]), is also designated 1.01, i.e. point number one located in zone number one.
Tung's points, instead of being associated with a conventional channel (for example Hegu L.I.-4 belongs to and acts on the arm yangming channel), are described as having a "reaction area" (6) that essentially describes the area of influence of that point or group of points. In some cases a reaction area corresponds to one of the zangfu and in other cases it represents an anatomical area. For example, some points used to treat post-stroke hemiplegia have the reaction area of the "extremities" (7). Certain points also have different reaction areas depending on the depth of needle insertion. Tung's point Ming Huang (8.12 [TEXT NOT REPRODUCIBLE IN ASCII]), located at the centre of the middle line of the medial aspect of the thigh, has a reaction area of the Kidney when needled superficially, the Liver when needled to a medium depth, and the Heart when needled deeply.
In general, Master Tung used his points on the head and hand to treat acute or more recent conditions, and needling these points most often achieves rapid and dramatic reduction of symptoms. Points on the leg, especially those proximal to the knees, are used to treat more chronic and complex conditions. This use of points in particular contrasts dramatically with TCM acupuncture, which utilises points on the thigh infrequently.
Characteristics of treatment and needle technique
Tung's acupuncture is characterised by the use of a minimal number of points in each treatment, usually no more than six. Master Tung favoured the use of large gauge needles (such as 0.40 mm, or 26 guage) and needled freehand, often times through clothing (8). There is a conspicuous lack of complex needle manipulation and there is no use of supplementation (bu fa) or drainage technique (xie fa). Needle depth is varied according to the condition, although Tung made ample use of deep needling (often touching the periosteum of underlying bone) and through-and-through needle techniques to connect multiple points with one needle.
Points are almost always needled distally and contralaterally to the site of disease or dysfunction, and points on the top of the body are used to treat the bottom and vice versa. For example, Tung's points on the plantar surface of the foot generally treat conditions of the head and brain/mind.
Points also treat diseases corresponding to the location of the point. For example, points on the forearm treat pain in the forearm, etc. Unlike conventional 14 channel acupuncture however, these points are not needled locally on the diseased side but rather on the healthy side of the body. Once needles are inserted they are retained for long periods of time, usually in excess of 30 or 45 minutes. Occasionally, throughout the treatment, needles are manipulated with even twirling to strengthen the therapeutic effect.
Point Selection and combination Dao yin needle technique [TEXT NOT REPRODUCIBLE IN ASCII]
One of the benefits of distal acupuncture point stimulation is that it frees up the diseased area for local stimulation (e.g., self-movement or massage). In the dao yin, or 'conducting qi', technique distal points are needled and then the patient is required to mobilise the diseased or painful area. For example, in cases of shoulder pain, point Tse Hua Chong (7.09 Si Hua Zhong [TEXT NOT REPRODUCIBLE IN ASCII]--similar in location to Tiaokou ST-38) is needled contralaterally to the painful side while the patient is asked to mobilise the painful shoulder. In cases where the patient is unable to move, the practitioner can move or manipulate the joint for the patient.
According to Chinese medicine, pain is the patient's subjective perception of stagnant qi and blood in an area. The dao yin needle technique is particularly effective in that it very strongly moves qi and blood in the channels through distal needling and moves qi locally through active physical movement or stimulation.
Dao ma needle technique [TEXT NOT REPRODUCIBLE IN ASCII]
The dao ma 'inverted horse' technique uses combinations of two or three points in a given area, most commonly arranged in a vertical line, to augment needle stimulation. These points are located near to each other, usually no more than two or three cun apart. On the hands and fingers however, these points are much closer together, usually less than one cun apart. In fact many of Tung's unique points are arranged in two or three point sets, meaning that these dao ma groups are always needled in combination rather than as single points.
Dao ma point groupings serve to increase needle stimulation in the treatment target area, thereby achieving more effective and immediate results when needling points distal to the area of disease.
Non-acupuncture therapies of Tung's acupuncture
Triangular needle bleeding therapy [TEXT NOT REPRODUCIBLE IN ASCII]
Bleeding therapy plays a major role in Tung's acupuncture, far more so than in 14 channel acupuncture. Master Tung believed that most chronic disease, painful conditions, and all fatal disease always involve stasis of qi and especially blood. Bleeding therapy in general strongly moves the blood, and the qi via the blood. Thus, bleeding therapy can be used to treat a wide variety of recalcitrant conditions.
In Tung's acupuncture, points over the entire body can be bled. Unlike in 14 channel acupuncture, Tung made frequent use of bleeding points on the trunk. Actually, the majority of Tung's points on both the dorsal and ventral trunk are never needled, only bled. While in Tung's acupuncture points are needled contralaterally to the side of pain or dysfunction, bleeding is typically done ipsilaterally.
Moxibustion and other miscellaneous therapies
The vast majority of treatment in Tung's lineage involves needling acupuncture points or bleeding therapy. Master Tung did, however, utilise other therapies when necessary. Moxibustion, while not performed as frequently as in 14 channel acupuncture, is used to warm and supplement points. For example, Tung's point Huo Fu Hai (3.07 [TEXT NOT REPRODUCBLE IN ASCII], located between the ulna and radius on the posterior forearm 8.5 cun proximal to the wrist joint) is stimulated with moxibustion to treat conditions related to anemia and general vacuity. Like many points treated with moxibustion, the application of moxa to this point is said to increase longevity. Master Tung preferred to have patients use moxibustion as a long-term daily home therapy rather than applying it as short-term treatment in his own clinic.
Master Tung also made use of cupping and scraping (gua sha) therapy as local treatments. Furthermore, while Tung was primarily an acupuncturist, he was well aware of the composition of classical herbal formulae and occasionally prescribed herbs in cases where he thought it was necessary. More commonly than using herbs however, Tung would prescribe simple dietary remedies for patients. A section on dietary recommendations for a variety of disorders is included in Tung's original Chinese language text (9). Thus, Master Tung was not only a talented acupuncturist, but also was an expert in all areas of Chinese medicine.
Classical Daoist (Taoist) therapies
While in the west it is commonly believed that Chinese medicine is synonymous with Daoist medicine, this is not necessarily the case. It is true that many advances in Chinese pharmacology were made by Daoist adepts, yet a great number of Daoist movements actually forbad their members from using herbal therapies or acupuncture in favour of purely religious methods of healing such as prayer, ritual petitions to Daoist deities, and the use of talismanic magic (fu zhou [TEXT NOT REPRODUCIBLE IN ASCII]) (10). Early texts of Chinese medicine, such as Sun Si Miao's Qian Jin Yao Fang, recognised the use of religious healing and included these therapies alongside herbal formulae or acupuncture protocols.
Master Tung was a devout practitioner of the Daoist religion. In his own clinic he occasionally wrote talismans for patients, to treat both physical ailments and social and psychological problems such as marital troubles. Master Tung's familiarity with these ancient shamanistic therapies demonstrates that he was well steeped in classical Chinese medicine before it was purged of therapies the government of the PRC deemed superfluous or superstitious.
Point example: Wu Hu (Five Tigers)
The points Wu Hu (1.27 [TEXT NOT REPRODUCIBLE IN ASCII]) are a commonly used dao ma set in Tung's acupuncture. They are a collection of five points evenly distributed along the radial border of the proximal phalanx of the thumb, located on the demarcation of the red and white skin. The Wu Hu points are associated with the reaction area of the Spleen, and according to Master Tung treat bony swellings, rheumatoid and osteo- arthritis, acute ankle pain, and other acute traumatic ligamentous injuries. Two or three of these points are needled simultaneously, contralaterally to the site of pain, while the patient then mobilises the affected area (an application of the dao yin needle technique combined with the dao ma needle technique).
The Wu Hu points treat conditions of both the upper and lower body. According to one of Tung's disciples, the more distal of the Wu Hu points treat conditions of the upper extremities, while the more proximal of the Wu Hu points treat conditions of the lower extremities (11). Generally, the Wu Hu points are needled perpendicularly with the tips of the needles touching the periosteum of the phalange.
[FIGURES 1-3 OMITTED]
Case study 1: ankle sprain
A 65-year-old patient presented to my office with an acute sprain of the left ankle. She had already been evaluated by her physician, and imaging tests showed no significant physical damage. She complained of pain around the entire ankle, which was quite swollen and hot to the touch. The only treatment she had received was a soft splint and the recommendation that she take analgesics as necessary.
In the office she was asked to sit and elevate her ankle and the soft cast was removed for comfort as well as to allow her to move the ankle slightly. The points for treatment were the three proximal points of the Wu Hu (1.27) set on the right thumb. The three points were needled to a depth of three to four millimetres, until the tip of the needle touched the periosteum of the phalanx, eliciting a heavy sensation. The patient was periodically asked to gently move the painful ankle and the needles were manipulated with a simple even twirling every 15 minutes. The needles were retained for 45 minutes and no other points were used during this treatment.
By the end of the treatment the patient reported a dramatic reduction in pain and could walk again with only a minimal limp. Furthermore by the end of the treatment there was barely any visible swelling of the ankle and on palpation the temperature of the skin had normalised to the same level as the healthy ankle.
Case study 2: spondylosis
An 80 year-old male presented with a main complaint of back pain. He had a diagnosis of spondylosis and fractured lumbar vertebrae, and presented with a severe kyphosis as well as a scoliosis (he had lost 12 centimetres in height in the last year alone). The pain began about four months prior to his first acupuncture treatment after he underwent chiropractic manipulation. The pain was worse in the morning when getting out of bed and after standing for any period of time, and walking was difficult. His tongue was pale and his pulse was deep and very weak. There were small spider naevi on his face near Chengqiang REN-24. In Chinese medicine terms he presented with a Kidney yang vacuity with local qi and blood stasis in the spine and lumbar area. In Tung's acupuncture the chin is associated with the Kidney and a dark colour or presence of spider naevi in this area shows a vacuity in the Kidney system, further corroborating the tongue and pulse findings.
It was impossible for this patient to lie down for treatment so he was treated sitting upright. The points used for treatment were Shui King (10.20 Shui Jin [TEXT NOT REPRODUCIBLE IN ASCII]), Shui T'ung (10.19 Shui Tong [TEXT NOT REPRODUCIBLE IN ASCII] ), Hou Chui (4.02 Hou Zhui [TEXT NOT REPRODUCIBLE IN ASCII]), Shou Ying (4.03 Shou Ying [TEXT NOT REPRODUCIBLE IN ASCII]), and Shen Kuan (7.18 Shen Guan [TEXT NOT REPRODUCIBLE IN ASCII]). Shui King and Shui T'ung are located on the face. Specifically, Shui T'ung is located 0.4 cun inferior to the corner of the mouth and Shui King is located 0.4 cun medial to Shui T'ung. These points have a reaction area of the Kidney and can be used to treat lumbar pain associated with Kidney vacuity (12). In this patient the points were needled with a 30 gauge 40 mm needle. The needle was inserted bilaterally into Shui King and then inserted through and through subcutaneously to Shui T'ung.
Shen Kuan is a major point in Tung's acupuncture for supplementing the Kidney and is located 1.5 cun inferior to the medial condyle of the tibia (the area of Yinlingquan SP-9) (13). For this treatment Shen Kuan was needled bilaterally with a 28 gauge 50mm needle to a depth of just under two cun. Hou Chui and Shou Ying are part of a dao ma group, and are needled together as a group more commonly than as single points. Hou Chui is located on the posterior arm, 2.5 cun proximal to the olecranon, and Shou Ying is located longitudinally two cun proximal to Hou Chui. As the name suggests, Hou Chui, Back Vertebra, is used to treat problems of the vertebrae. Both Hou Chui and Shou Ying have a reaction area of the spine and are indicated for spinal pain, prolapsed intervertebral disc, lumbar pain and nephritis (14). These two points were needled on the left arm only as the pain was worse on the right side. These two points were also needled with 28 gauge 50mm needles and inserted until the tips of the needles touched the humerus. In total only six needles were used per treatment.
After the first treatment the patient noticed that there was no longer any pain getting out of bed in the morning although there was some pain by the end of the day when he was tired. He was able to stand, however, for much longer periods of time without discomfort. After the second treatment he was able to stand and sit straighter than he had before and the pain relief lasted almost the entire week between treatments. Furthermore, the visible veins on his face were thinner and lighter in colour. To date the patient has had three treatments in all.
Conclusion
Tung's acupuncture represents a rare example of a traditional family lineage of Chinese medicine that has survived into the present day. The uniqueness of Tung's acupuncture challenges and expands knowledge of the basic tenets of acupuncture such as the location of points, their arrangement in channels and their major indications. Tung's approach to acupuncture and Chinese medicine therefore reminds practitioners that it is impossible to point to any one school of thought and practice and believe it is the sole inheritor of the vast ocean of Chinese medicine practised from the days of the Yellow Emperor.
Master Tung was a physician with exceptional generosity, bravery and foresight to teach his family's medical heritage to outsiders for the sake of continuing the lineage and benefiting patients with an exceptionally effective therapy. Perhaps this willingness to share previously 'secret' information will encourage other Chinese medical practitioners, who may still practise family lineages, to open their teachings to outsiders so that they may continue into the future and benefit many more patients than one practitioner alone can treat.
Acknowledgement
Special thanks to Dr. Palden Carson, M.D., president of the World Tung's Acupuncture Association, a personal disciple of Master Tung, and my teacher who has lead me into the wonderful practice of Tung's Orthodox Acupuncture. He was extraordinarily generous in providing information for this article as well as offering corrections and suggestions before publication.
Bibliography
Carson, P. (1988) Tung's Orthodox Acupuncture. Taipei: Lien Ho Press, Co.
Tung, CC. (1973) Tung Shih Chen Chiu Cheng Ching Ch'i Hsueh Hsueh. Taipei: Hsin Ya Publications Ltd.
Yang, WJ. (1999) Dong Shi Qi Xue Zhen Jiu Xue. Taipei: Chih Yuan Bookstore.
Notes
(1) For a more in-depth discussion of both the positive and negative aspects surrounding the creation of TCM see Fruehauf, Heiner. "Science, Politics, and the Making of TCM: Chinese Medicine in Crisis." Journal of Chinese Medicine 61; October 1999.
(2) Tung is the Wade-Giles Romanisation of the Chinese family name. In pinyin Romanisation (the system created by and used currently in the PRC and in most academic circles) the name is Romanised "Dong". Either way, the pronunciation is the same, with a "d" sound at the beginning. Master Tung was a very staunch anticommunist and thus resisted the use of anything related to the communist government of mainland China, including the pinyin system. When Master Tung was alive he himself preferred the spelling "Tung" to represent his name. Thus, in accord with the practice of the World Tung's Acupuncture Association, throughout this article Wade-Giles Romanisation will be used for his name. However in the years since Master Tung's passing, the pinyin system has gradually become the standard academic method of Romanising Chinese, even in Taiwan. Thus all other Chinese medical terms will be given in pinyin. Tung's point names will be given in Wade-Giles first and Pinyin second for those not familiar with the Wade-Giles system.
(3) Historical information was generously provided by Dr. Palden Carson.
(4) Master Tung was very proud of being a native of Shandong. On the cover of his book and on his business cards, Master Tung was listed as "Shandong Tung Ching Chang" (See Tung, 1973) and never referred to himself as either "Taiwanese" or "Mainland Chinese". This is in direct conflict with some texts now being published in Taiwan that claim Master Tung's acupuncture is a form of "Taiwanese acupuncture."
(5) In Chinese [TEXT NOT REPRODUCIBLE IN ASCII]. The term "curious" is the same word used to describe the Eight Extraordinary (Curious) Vessels and the Six Curious Bowels (Fu). (See Tung, 1973).
(6) The original term for "reaction area" in Master Tung's book is Shen Jing ([TEXT NOT REPRODUCIBLE IN ASCII]). This term is usually translated into English as "nerve".
(7) The point Chung Chiu Li (8.25 Zhong Jiu Li [TEXT NOT REPRODUCIBLE IN ASCII]), for example, has a reaction area of the Lung and Extremities. It is located on the median line of the lateral thigh, nine cun above the upper margin of the patella (or at the midpoint of the thigh).
(8) Of course, this directly contradicts standard clean needle technique protocols that acupuncturists are taught today. However, in ancient China (especially in the cold north such as in Shandong province) this was common practice.
(9) Tung, appendix pg. 15-18.
(10) Kohn, Livia. Daoism and Chinese Culture. Cambridge: Three Pines Press, 2001, pg. 75.
(11) Yang, pg. 26.
(12) Carson, pg. 199-200.
(13) Ibid., pg. 125.
(14) Ibid., pg. 62-63.
Henry McCann is a licensed acupuncturist, a licensed Doctor of Acupuncture, and a Diplomate in Oriental Medicine (NCCAOM). He graduated from Oberlin College in Ohio and the New England School of Acupuncture in Massachusetts, and was a Fulbright research fellow to the University of the Ryukyus in Okinawa, Japan. Henry serves on the New Jersey State Acupuncture Examining Board by gubernatorial appointment, and is a member and the New Jersey representative of the World Tung's Acupuncture Association. He can be reached at www.newjerseyacupuncture.com.
Table 1: Point
Distribution
in Tung's
Acupuncture
Zone Location Number of Points
1 Fingers 27
2 Palm and dorsal hand 11
3 Forearm 16
4 Upper Arm 17
5 Plantar aspect of foot 6
6 Dorsal foot 6
7 Leg/Calf 28
8 Thigh 32
9 Ear 8
10 Head 25
Note: There are also more than 160 additional points on the neck, and
both the dorsal and ventral trunk.
Magnets applied to acupuncture points as therapy--a literature review
By: Colbert, Agatha P.,Cleaver, James,Brown, Kimberly Ann,Harling, Noelle,Hwang, Yuting,Schiffke, Heather C.,Brons, John,Qin, Youping
Abstract
Objectives To summarise the acu-magnet therapy literature and determine if the evidence justifies further investigation of acu-magnet therapy for specific clinical indications.
Methods Using various search strategies, a professional librarian searched six electronic databases (PubMed, AMED, ScienceDirect College Edition, China Academic Journals, Acubriefs, and the in-house Journal Article Index maintained by the Oregon College of Oriental Medicine Library). English and Chinese language human studies with all study designs and for all clinical indications were included. Excluded were experimental and animal studies, electroacupuncture and transcranial magnetic stimulation. Data were extracted on clinical indication, study design, number, age and gender of subjects, magnetic devices used, acu-magnet dosing regimens (acu-point site of magnet application and frequency and duration of treatment), control devices and control groups, outcomes, and adverse events.
Results Three hundred and eight citations were retrieved and 50 studies met our inclusion criteria. We were able to obtain and translate (when necessary) 42 studies. The language of 31 studies was English and 11 studies were in Chinese. The 42 studies reported on 32 different clinical conditions in 6453 patients from 1986-2007. A variety of magnetic devices, dosing regimens and control devices were used. Thirty seven of 42 studies (88%) reported therapeutic benefit. The only adverse events reported were exacerbation of hot flushes and skin irritation from adhesives.
Conclusions Based on this literature review we believe further investigation of acu-magnet therapy is warranted particularly for the management of diabetes and insomnia. The overall poor quality of the controlled trials precludes any evidence based treatment recommendations at this time.
Keywords Acu-magnet therapy, static magnetic field, dosimetry, permanent magnet, acupuncture points.
Introduction
As part of clinical practice, acupuncturists often apply magnets to acupuncture points as either an adjunct to needling or as a stand alone therapy.(1-4) Magnets (gold plated or non-plated 800 Gauss magnets) are often left on key acupuncture points after an acupuncture needle treatment with the intention of prolonging the therapeutic effect. Stronger magnets (3000 Gauss) may be used with or without an electromagnetic device as the primary treatment in lieu of needling. (5) Practitioners of magnetotherapy teach patients to apply magnets to various body parts as a self care intervention for a number of conditions. (6-8) Although site of magnet placement is presumably an important therapeutic consideration, a recent critical review of static magnetic field (SMF) dosing parameters found that the optimal site for magnet placement on the body has not been determined. (9) However, in 5 of 56 studies reviewed, when magnets were explicitly placed on tender points or trigger points, (10-14) positive outcomes were consistently reported, whereas mixed outcomes were reported in studies in which magnets were simply applied to 'where it hurts'. Like myofascial trigger points, acupuncture points are believed to be responsive to physical or electrical inputs such as needling, (15) transcutaneous electrical stimulation, (16) ultrasound and digital massage, (17) moxibustion, (19) laser treatments, '8 and other electromagnetic therapies. (19)
Paralleling the growing popular use of magnets, biological mechanisms including influences on blood flow, (20) microvascular remodelling, (21) oedema reduction" and blockade of sensory neurons (23) have been identified as providing biological plausibility for the potential therapeutic benefits of static magnetic fields. If the application of permanent magnets does exert a physiological effect, especially when applied to electromagnetically active sites such as acupuncture points or trigger points, it seems appropriate to evaluate the practice of acu-magnet therapy and begin relevant research to determine its effectiveness.
Our two goals in conducting this literature review are to summarise the acu-magnet therapy literature and determine if current evidence justifies further investigation of acu-magnet therapy for particular clinical indications. We define 'acu-magnet therapy' as stimulation of an acupuncture point with a static magnetic field (SMF) that is generated by a permanent magnet.
Methods
We surveyed the journal literature to identify clinical studies involving the use of magnets applied to acupuncture points in humans. A professional librarian (NH) searched six electronic databases, including PubMed, AMED, ScienceDirect College Edition, China Academic Journals, Acubriefs, and the in-house Journal Article Index maintained by the Oregon College of Oriental Medicine Library. Each database was searched from inception. All searches occurred in December 2007, with two exceptions. Acubriefs was searched in January 2008. The China Academic Journals search was conducted in February 2006 for a closely-related study and could not be rerun in December 2007 due to loss of database access.
We employed various search strategies depending on the size and scope of the database. In one case, a simple keyword search using the term 'magnet' was sufficient to retrieve relevant articles with reasonable precision and recall. In most cases, a more sophisticated strategy involving multiple synonyms for permanent magnet--and acupuncture-related concepts, subject headings, truncation, and excluded terms was required (details available from author). The primary author examined the resulting 308 references to identify articles for analysis, screening by title, abstract when it was available, and full text where necessary.
Inclusion and exclusion criteria
We selected studies for inclusion using the following criteria. Study design--clinical trials, case series and case reports were all included because our goal was to summarise as much of the clinical literature as possible. Clinical indication--we included studies involving any clinical diagnosis or medical condition in humans. Type of magnetic field therapy--only studies involving the stimulation of acupuncture points by application of permanent magnets were included. Studies reporting on electroacupuncture and transcranial magnetic stimulation were excluded. We also excluded experimental and animal studies.
Publication type--duplicate publications were excluded. Editorials and letters were excluded because they fail to provide sufficient information with which to evaluate acu-magnet treatment parameters. Only English and Chinese language articles were included. Eighteen additional articles in Chinese met our inclusion criteria but were ultimately excluded from analysis either because the full text article could not be obtained or due to our limited resources for full and accurate translation.
Data extraction and synthesis
Six acupuncture researchers extracted data from the final 42 studies on: clinical condition, study design, number, age and gender of subjects, magnetic devices used, acu-magnet dosing regimen, control devices and/or control groups, outcomes, and adverse events. The authors summarised the extracted data. A synthesis of the controlled trials and observational studies is provided in Tables 1 and 2.
Results
Of the 42 articles reviewed, (24-65) 31 were published in English and 11 in Chinese. Thirty four studies were conducted in China, five studies in the USA and three in Finland. All studies were published between 1986 and 2007. Five of the total 34 authors contributed more than one article. Articles appeared in 12 journals, 10 of which were Chinese medicine or acupuncture journals. The remaining two were Western medical journals.
Thirty two clinical indications were evaluated in the 42 studies. Three studies were conducted on insomnia in the elderly. (52;54;55) Two studies each were conducted on diabetes, (27;46) obesity, (56;61) hypertension, (26;32) temporomandibular joint disorder, (36;39) depression, (28;64) chemotherapy induced vomiting (44;45) headache (58;59) and gallbladder disease. (42;47) Single studies were conducted on stroke, (38) facial paralysis (40) benign prostatic hyperplasia, (41) hyperlipidaemia, (65) hiccup, (31) pinworms, (62) chronic leg ulcers, (35) phantom limb pain, (57) pseudocyst, (63) magnets as an adjunct anesthetic, (33) and various psychiatric and neurological disorders, (37;43;49-51) musculoskeletal, (30;48;53) and women's health conditions. (24;25;34;60)
Study designs
We included all research study designs in this review because our intent was to provide a comprehensive summary of the available literature and generate hypotheses for further research. We identified an equal number of case series (or case reports) and controlled trials. The controlled trials were of consistently poor quality as defined by the Jadad scale. (66) The only Jadad criterion met by the studies was the use of words such as 'random', 'randomly' or 'randomised.'
Demographics
The total number of subjects reported in the 42 studies was 6453, with 3101 males, 2791 females, and 561 subjects whose gender was not described. Age of study participants varied from 7 years to greater than 82 years. The majority of the studies (30 out of 42, or 71%) involved fewer than 100 subjects: 16 studies had 50 or fewer subjects, and 14 had between 51 and 100 subjects. Only two studies (both case series) were of a large scale. Li et al reported on 1500 patients with peripheral facial paralysis, (40) and He et al (29) described the results of acumagnet needling in 808 subjects (the majority were paediatric patients) with a wide variety of conditions. Except for gender specific disorders (eg labour pain, (34) prostate disorders (41)) studies included participants of both genders.
Outcomes
The majority of studies (37 out of 42, or 88%) reported positive outcomes. Only one study reported no benefit. (24) Patients in that study experienced no improvement or a worsening of hot flush symptoms associated with magnet application. The results of another study involving patients with migraine headache were inconclusive because of a high dropout rate; 7 of 13 participants dropped out because of poor outcomes or adverse reactions. (59) In three controlled trials, that studied the effects of magnets on high blood pressure, (32) temporomandibular joint disease, (39) and hyperlipidaemia, (65) improvement was observed in both the active and control groups, with no significant difference between groups.
Magnets: devices, materials, strengths, polarities and methods of application
Forty of the 42 studies provided at least partial descriptions of the magnetic devices applied, which included three types of magnets: flat rectangular or circular discs, beads or pellets, and magnetic acupuncture needles. Many studies neglected to report material composition of magnets and/or magnetic field strengths. In other studies there was ambiguity as to whether the reported strength was the manufacturer's Gauss rating (the internal core strength of the magnet) or the surface field strength. Surface field strengths of therapeutic magnets usually range between 300E to 2500E In two instances, (48;65) the magnetic intensities were reported respectively as 8000E and 5000E which we assume were the manufacturer's Gauss ratings rather than the surface field strengths.
Of 20 studies using plates or discs, 14 reported dimensions and magnetic strengths. Seven studies used circular discs ranging from 1.5 to 7mm in diameter and 1-2.5mm in thickness. Seven studies used rectangular or square plates varying between 8-50mm in length and 2-7mm in thickness. Magnetic beads or pellets were used in 12 studies, of which eight provided dimensions and six provided magnetic field strengths. Diameters ranged from 0.3-13mm and magnetic strengths ranged from 50E to 3000E Eight studies used magnetic acupuncture needles made of rare earth metals. Tip dimensions were not given but were assumed to be similar to typical Chinese acupuncture needles. Five studies reported magnetic needle strengths of 180E to 5000E
Only 7 of 42 studies mentioned which pole of the magnet faced the skin. Terms such as 'alternating pole magnets (24) or 'disparate poles (38) or 'north pole' (31;35,44;64) were used without a precise definition of terms. A commonly held belief among clinicians is that different magnetic pole applications lead to different outcomes, but this belief has not been tested in any clinical trials. Furthermore there is no established naming convention among clinicians for defining north and south poles.
Methods of magnet application were not described in 18 of 42 (43%) of studies (Table 3). When reported, discs, plates and beads or pellets were most often attached to the skin with adhesive tape. In two cases, the disc or beads were rotated above the skin without physical contact. (47;50) Magnetic acupuncture needles were either inserted 0.5-1.5 can depending on location, (31;61;65) or simply touched the skin without penetration. (30;43) In four studies, magnets were sewn into garments and worn at the desired location. (28;44;45;62) In one instance, children drank magnetised water to treat ascariasis. (62)
The sites for magnet application also varied (Table 4). Many researchers (48%) applied magnets to auricular (ear) acupuncture points. The ear acupuncture points most often used were Shenmen, Kidney, Liver, and Occiput. Body and scalp acupuncture points were also stimulated, as were local and distal points in accordance with acupuncture diagnostic theory. The choice of acupuncture points varied depending on clinical indication.
Frequency and duration of magnet application
There was no standard protocol for frequency or duration of magnet application in the studies reviewed. In the case series, durations of application varied from 1-3 minutes (30) to near continuous wear for several years. (27;49) In the controlled trials, frequency of application varied from a continuous 72 hour wear to continuous 30 day wear with removal and replacement of magnets every 2-3 days.
Control devices and control groups
The most common sham control device used in the controlled trials was a non-magnetic needle or ear seeds, applied to the same points as the magnetic needles or magnets. Non-magnetised metal objects were also used as controls as were herbs and vitamins. Magnetic devices were sometimes applied to non acupuncture sites or non-magnetised discs to non-acupuncture sites.
Magnets as adjunct to standard care
Although not always specifically described as such, in more than half the studies, magnets appear to have been used as an adjunct to standard care. In some cases magnets were applied in addition to acupuncture needling, moxibustion or Chinese herbs. Magnets on acupuncture points served as an adjunct to standard care for diabetes management, (27;46) antihypertensive therapy, (26) antiemetic therapy (44;45) and antipsychotic therapy. (51) In studies of insomnia in the elderly, magnets served as a stand alone therapy. (52;54)
Adverse events
Adverse events included an exacerbation of hot flushes (24) and skin irritation due to the adhesives that held the magnets to the body. (52)
Discussion
Our goals in conducting this literature review were: 1) to summarise the outcomes and techniques of various acu-magnet intervention studies that have been published to date, primarily in English; and 2) to identify clinical conditions with positive outcomes, and assess whether a rigorous investigation of acu-magnet therapy for specific conditions is warranted. The most striking observation from this review was the overwhelmingly positive outcomes reported. A note of caution is that 34 of the 42 studies evaluated were conducted in China where there is a significant bias toward publishing positive trials." In addition, the studies were either case series or poor quality controlled trials, so no claims for the efficacy of acu-magnet therapy can be made at this time. Nonetheless, the large number of subjects (a total of 6453) in these studies suggests that many patients are treated with acu-magnet therapy in clinical practice, particularly in China, and report meaningful clinical improvement.
The single N of 1 study warrants special comment. (27) When evaluating clinical benefit for an individual patient, the N of 1 randomised controlled trial ranks highest in terms of evidence based hierarchy for that individual. An N of 1 controlled trial, involves the use of a crossover design to treat a single patient. In random order, the patient receives one period of active therapy and one period of placebo. The patient is kept blind to allocation, and treatment outcomes are monitored. In her N of 1 study, Chen used ear acu-magnet therapy, as an adjunct to standard care, to treat a patient with long standing diabetes mellitus. (27) The study looked at fasting blood glucose levels as the primary outcome measure. For seven days placebo discs were applied to the pancreas point of the left ear and the thalamus points of both ears. Then after a three day washout period, 2500G magnetic discs were applied to those same auricular acupuncture points. Results of this trial showed that fasting blood glucose during the placebo week was 194[+ or -]15mg/dL. During the active magnet week, fasting glucose dropped to 136[+ or -]10mg/dL. Having determined that auricular magnets applied to this patient using this dosing regimen were effective, the clinician researcher then used magnetic ear clips for ongoing treatment as an adjunct to standard diabetes management. At four year follow up, evaluation of this patient showed a persistent decrease in fasting blood glucose and HbAIC with no further progression of the patient's diabetic neuropathy.
We believe that the preliminary evidence for two conditions, insomnia in elderly patients (52;54) and glucose control in diabetics, (27) justify further clinical trials to evaluate the effectiveness of acu-magnet therapy. The studies of Suen et al (52;54) and Chen 21 should be replicated as the first step in this program of research on acu-magnet therapy.
Information gained from this review will help to guide protocol development for future studies. Of particular relevance to future trials is the fact that adverse reactions associated with acu-magnet therapy were reported in only two studies. In one study, high intensity magnets (surface field strength ~2000G) were left on six clinically 'powerful' acupuncture points for 72 hours, to treat hot flushes. (24) Participants in this study had an exacerbation of their hot flush symptoms. An important lesson learned is that dosing parameters such as number of acupuncture points to treat simultaneously, the strength of the magnet and duration of magnet application should be tested and optimised prior to conducting a clinical trial. Skin irritation associated with the adhesive securing the tape may need to be considered when adverse reactions are encountered.
Acu-magnet therapy research shares many of the methodological challenges faced by acupuncture research in general. At a minimum, a rationale for acu-point selection and style of acupuncture used, need to be justified. Acupuncture points might be selected for a number of reasons including: following traditional Chinese medicine theory or Japanese style acupuncture or treatment of ah shi or trigger points, or using one of the acupuncture microsystems such as Korean hand acupuncture, scalp acupuncture or auriculotherapy. The acupuncture points should be described with the standard nomenclature of the World Health Organisation. (68)
Specifics of treatment, including the magnetic device itself (material composition, strength, dimensions and polarity) and the SMF dosing regimen should be detailed. The exact dosing regimen should include the site and method of magnet application, and frequency and duration of application. The dosing regimen should be pretested, optimised and precisely documented. We discovered in this review that the most lasting beneficial effects were associated with long term magnet use. (27;28;49;55) When magnets are applied for a prolonged time period or when patients self-apply magnets, the small magnetic discs may be secured to the skin via earrings or clips (in the case of auricular points) or sewn into a garment to be worn over the acu-point. If, on the other hand, high intensity magnets are applied during an in-office treatment, the method of application may be a needle, a stronger magnet or perhaps an electromagnetic device.
Polar configuration of the magnet(s) used is a special concern in the acupuncture paradigm as acupuncturists may use north and south poles on a pair of acupuncture points to either 'tonify' or 'disperse'. Terminology used to describe the poles of magnets is confusing in the literature. The term bionorth is used by some clinicians to describe what physicists denote the south pole of a magnet, ie the side of the magnet that attracts the south seeking needle of a compass. For clarity of meaning and consistency of reporting, we recommend that authors state which pole faced the skin and then define that pole with reference to a compass and/or a geographic pole. For example, one might report 'we applied the 'north' pole of the magnet to the skin and we define the 'north pole' as that side of the magnet that attracts the north seeking compass needle.' Or researchers might also report, 'When suspended by a string, the side of the magnet that faced the skin orients itself to face the earth's geographic south pole'.
Blinding subjects in acu-magnet therapy trials is problematic because magnetic properties are readily detected, making it easy for trial participants to deliberately or unintentionally discover whether their device is magnetised or not. We may not be able to use low strength magnets as sham controls because we still do not know the minimal effective dose of SMF therapy. Effects have been reported with magnets having field strengths as low as 66G. (55) Another potential control device used in some studies is semen vaccariae, a small seed which the investigators assumed to have no therapeutic effect as long as no pressure was applied to it, semen vaccariae, however, is considered a significant blood 'vitaliser' by Chinese herbalists, which may preclude its use as a sham control. Non-acupuncture sites may also be used as sham controls; however, many so-called 'sham points' have a physiological effect when stimulated with a needle. It is unclear whether or not a SMF placed anywhere on the skin might also have an effect.
Strengths and limitations of this review
The primary strength of our literature review is that it organises and summarises the available literature on acu-magnet therapy. No previous reviews of the acu-magnet literature have been conducted. Another strength is our sampling of related Chinese language literature. The limitations pertain to being unable to access other language literature, especially Japanese. Acu-magnet therapy is commonly practised in Japan. We also acknowledge the limitation of having no access to EMBASE, an electronic database where much of the European literature is found. We consider this project a first step toward developing a more rigorous program of research into acu-magnet therapy.
Future directions
This review has generated a number of questions to be answered in future clinical trials. These questions are summarised in Table 6. We recently initiated a small pilot study in an attempt to replicate Chen's findings of improved glucose control in diabetic patients with the use of ear acu-magnets (27) Our study intends to evaluate the use of non-magnetized pellets as sham controls. We will assess a dosing regimen of between 3-5 magnets (800G surface field strength, north pole facing the skin) applied for a one week period. If our findings show promise we will move forward with a full scale randomised controlled trial using magnets and sham controls to assess the efficacy of acu-magnet therapy as an adjunct to standard care for Type 2 diabetes mellitus. If our findings are negative we will conduct another pilot study using an alternate SMF dosing regimen.
Conclusions
In the absence of any consistent terminology we coined the term acu-magnet therapy to describe the application of magnets on acupuncture points as a distinct modality. We believe that further investigation of acu-magnet therapy as an adjunctive treatment for diabetes and for insomnia in the elderly is warranted based on findings from this review. Future trials should be rigorously conducted according to STRICTA (69) and CONSORT (70) guidelines, while paying special attention to the unique methodological and dosimetry issues associated with static magnetic field therapy. (9) The overall poor quality of the studies in this review precludes any evidence based treatment recommendations at this time.
Conflict of interest
The authors report no conflict of interest with any of the material presented in this manuscript.
Sources of Support
This study was funded in part by the National Center for Complementary and Alternative Medicine, National Institutes of Health (R21 AT003293).
Summary box
Many practitioners apply magnets to acupuncture points as
therapy
This study systematically reviewed all the available clinical
trials
37 out of 42 studies reported therapeutic benefit of
magnets
The quality of the evidence is not sufficient to make
treatment recommendations
The positive findings are sufficiently interesting to justify
further research
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Abstract
Objectives To summarise the acu-magnet therapy literature and determine if the evidence justifies further investigation of acu-magnet therapy for specific clinical indications.
Methods Using various search strategies, a professional librarian searched six electronic databases (PubMed, AMED, ScienceDirect College Edition, China Academic Journals, Acubriefs, and the in-house Journal Article Index maintained by the Oregon College of Oriental Medicine Library). English and Chinese language human studies with all study designs and for all clinical indications were included. Excluded were experimental and animal studies, electroacupuncture and transcranial magnetic stimulation. Data were extracted on clinical indication, study design, number, age and gender of subjects, magnetic devices used, acu-magnet dosing regimens (acu-point site of magnet application and frequency and duration of treatment), control devices and control groups, outcomes, and adverse events.
Results Three hundred and eight citations were retrieved and 50 studies met our inclusion criteria. We were able to obtain and translate (when necessary) 42 studies. The language of 31 studies was English and 11 studies were in Chinese. The 42 studies reported on 32 different clinical conditions in 6453 patients from 1986-2007. A variety of magnetic devices, dosing regimens and control devices were used. Thirty seven of 42 studies (88%) reported therapeutic benefit. The only adverse events reported were exacerbation of hot flushes and skin irritation from adhesives.
Conclusions Based on this literature review we believe further investigation of acu-magnet therapy is warranted particularly for the management of diabetes and insomnia. The overall poor quality of the controlled trials precludes any evidence based treatment recommendations at this time.
Keywords Acu-magnet therapy, static magnetic field, dosimetry, permanent magnet, acupuncture points.
Introduction
As part of clinical practice, acupuncturists often apply magnets to acupuncture points as either an adjunct to needling or as a stand alone therapy.(1-4) Magnets (gold plated or non-plated 800 Gauss magnets) are often left on key acupuncture points after an acupuncture needle treatment with the intention of prolonging the therapeutic effect. Stronger magnets (3000 Gauss) may be used with or without an electromagnetic device as the primary treatment in lieu of needling. (5) Practitioners of magnetotherapy teach patients to apply magnets to various body parts as a self care intervention for a number of conditions. (6-8) Although site of magnet placement is presumably an important therapeutic consideration, a recent critical review of static magnetic field (SMF) dosing parameters found that the optimal site for magnet placement on the body has not been determined. (9) However, in 5 of 56 studies reviewed, when magnets were explicitly placed on tender points or trigger points, (10-14) positive outcomes were consistently reported, whereas mixed outcomes were reported in studies in which magnets were simply applied to 'where it hurts'. Like myofascial trigger points, acupuncture points are believed to be responsive to physical or electrical inputs such as needling, (15) transcutaneous electrical stimulation, (16) ultrasound and digital massage, (17) moxibustion, (19) laser treatments, '8 and other electromagnetic therapies. (19)
Paralleling the growing popular use of magnets, biological mechanisms including influences on blood flow, (20) microvascular remodelling, (21) oedema reduction" and blockade of sensory neurons (23) have been identified as providing biological plausibility for the potential therapeutic benefits of static magnetic fields. If the application of permanent magnets does exert a physiological effect, especially when applied to electromagnetically active sites such as acupuncture points or trigger points, it seems appropriate to evaluate the practice of acu-magnet therapy and begin relevant research to determine its effectiveness.
Our two goals in conducting this literature review are to summarise the acu-magnet therapy literature and determine if current evidence justifies further investigation of acu-magnet therapy for particular clinical indications. We define 'acu-magnet therapy' as stimulation of an acupuncture point with a static magnetic field (SMF) that is generated by a permanent magnet.
Methods
We surveyed the journal literature to identify clinical studies involving the use of magnets applied to acupuncture points in humans. A professional librarian (NH) searched six electronic databases, including PubMed, AMED, ScienceDirect College Edition, China Academic Journals, Acubriefs, and the in-house Journal Article Index maintained by the Oregon College of Oriental Medicine Library. Each database was searched from inception. All searches occurred in December 2007, with two exceptions. Acubriefs was searched in January 2008. The China Academic Journals search was conducted in February 2006 for a closely-related study and could not be rerun in December 2007 due to loss of database access.
We employed various search strategies depending on the size and scope of the database. In one case, a simple keyword search using the term 'magnet' was sufficient to retrieve relevant articles with reasonable precision and recall. In most cases, a more sophisticated strategy involving multiple synonyms for permanent magnet--and acupuncture-related concepts, subject headings, truncation, and excluded terms was required (details available from author). The primary author examined the resulting 308 references to identify articles for analysis, screening by title, abstract when it was available, and full text where necessary.
Inclusion and exclusion criteria
We selected studies for inclusion using the following criteria. Study design--clinical trials, case series and case reports were all included because our goal was to summarise as much of the clinical literature as possible. Clinical indication--we included studies involving any clinical diagnosis or medical condition in humans. Type of magnetic field therapy--only studies involving the stimulation of acupuncture points by application of permanent magnets were included. Studies reporting on electroacupuncture and transcranial magnetic stimulation were excluded. We also excluded experimental and animal studies.
Publication type--duplicate publications were excluded. Editorials and letters were excluded because they fail to provide sufficient information with which to evaluate acu-magnet treatment parameters. Only English and Chinese language articles were included. Eighteen additional articles in Chinese met our inclusion criteria but were ultimately excluded from analysis either because the full text article could not be obtained or due to our limited resources for full and accurate translation.
Data extraction and synthesis
Six acupuncture researchers extracted data from the final 42 studies on: clinical condition, study design, number, age and gender of subjects, magnetic devices used, acu-magnet dosing regimen, control devices and/or control groups, outcomes, and adverse events. The authors summarised the extracted data. A synthesis of the controlled trials and observational studies is provided in Tables 1 and 2.
Results
Of the 42 articles reviewed, (24-65) 31 were published in English and 11 in Chinese. Thirty four studies were conducted in China, five studies in the USA and three in Finland. All studies were published between 1986 and 2007. Five of the total 34 authors contributed more than one article. Articles appeared in 12 journals, 10 of which were Chinese medicine or acupuncture journals. The remaining two were Western medical journals.
Thirty two clinical indications were evaluated in the 42 studies. Three studies were conducted on insomnia in the elderly. (52;54;55) Two studies each were conducted on diabetes, (27;46) obesity, (56;61) hypertension, (26;32) temporomandibular joint disorder, (36;39) depression, (28;64) chemotherapy induced vomiting (44;45) headache (58;59) and gallbladder disease. (42;47) Single studies were conducted on stroke, (38) facial paralysis (40) benign prostatic hyperplasia, (41) hyperlipidaemia, (65) hiccup, (31) pinworms, (62) chronic leg ulcers, (35) phantom limb pain, (57) pseudocyst, (63) magnets as an adjunct anesthetic, (33) and various psychiatric and neurological disorders, (37;43;49-51) musculoskeletal, (30;48;53) and women's health conditions. (24;25;34;60)
Study designs
We included all research study designs in this review because our intent was to provide a comprehensive summary of the available literature and generate hypotheses for further research. We identified an equal number of case series (or case reports) and controlled trials. The controlled trials were of consistently poor quality as defined by the Jadad scale. (66) The only Jadad criterion met by the studies was the use of words such as 'random', 'randomly' or 'randomised.'
Demographics
The total number of subjects reported in the 42 studies was 6453, with 3101 males, 2791 females, and 561 subjects whose gender was not described. Age of study participants varied from 7 years to greater than 82 years. The majority of the studies (30 out of 42, or 71%) involved fewer than 100 subjects: 16 studies had 50 or fewer subjects, and 14 had between 51 and 100 subjects. Only two studies (both case series) were of a large scale. Li et al reported on 1500 patients with peripheral facial paralysis, (40) and He et al (29) described the results of acumagnet needling in 808 subjects (the majority were paediatric patients) with a wide variety of conditions. Except for gender specific disorders (eg labour pain, (34) prostate disorders (41)) studies included participants of both genders.
Outcomes
The majority of studies (37 out of 42, or 88%) reported positive outcomes. Only one study reported no benefit. (24) Patients in that study experienced no improvement or a worsening of hot flush symptoms associated with magnet application. The results of another study involving patients with migraine headache were inconclusive because of a high dropout rate; 7 of 13 participants dropped out because of poor outcomes or adverse reactions. (59) In three controlled trials, that studied the effects of magnets on high blood pressure, (32) temporomandibular joint disease, (39) and hyperlipidaemia, (65) improvement was observed in both the active and control groups, with no significant difference between groups.
Magnets: devices, materials, strengths, polarities and methods of application
Forty of the 42 studies provided at least partial descriptions of the magnetic devices applied, which included three types of magnets: flat rectangular or circular discs, beads or pellets, and magnetic acupuncture needles. Many studies neglected to report material composition of magnets and/or magnetic field strengths. In other studies there was ambiguity as to whether the reported strength was the manufacturer's Gauss rating (the internal core strength of the magnet) or the surface field strength. Surface field strengths of therapeutic magnets usually range between 300E to 2500E In two instances, (48;65) the magnetic intensities were reported respectively as 8000E and 5000E which we assume were the manufacturer's Gauss ratings rather than the surface field strengths.
Of 20 studies using plates or discs, 14 reported dimensions and magnetic strengths. Seven studies used circular discs ranging from 1.5 to 7mm in diameter and 1-2.5mm in thickness. Seven studies used rectangular or square plates varying between 8-50mm in length and 2-7mm in thickness. Magnetic beads or pellets were used in 12 studies, of which eight provided dimensions and six provided magnetic field strengths. Diameters ranged from 0.3-13mm and magnetic strengths ranged from 50E to 3000E Eight studies used magnetic acupuncture needles made of rare earth metals. Tip dimensions were not given but were assumed to be similar to typical Chinese acupuncture needles. Five studies reported magnetic needle strengths of 180E to 5000E
Only 7 of 42 studies mentioned which pole of the magnet faced the skin. Terms such as 'alternating pole magnets (24) or 'disparate poles (38) or 'north pole' (31;35,44;64) were used without a precise definition of terms. A commonly held belief among clinicians is that different magnetic pole applications lead to different outcomes, but this belief has not been tested in any clinical trials. Furthermore there is no established naming convention among clinicians for defining north and south poles.
Methods of magnet application were not described in 18 of 42 (43%) of studies (Table 3). When reported, discs, plates and beads or pellets were most often attached to the skin with adhesive tape. In two cases, the disc or beads were rotated above the skin without physical contact. (47;50) Magnetic acupuncture needles were either inserted 0.5-1.5 can depending on location, (31;61;65) or simply touched the skin without penetration. (30;43) In four studies, magnets were sewn into garments and worn at the desired location. (28;44;45;62) In one instance, children drank magnetised water to treat ascariasis. (62)
The sites for magnet application also varied (Table 4). Many researchers (48%) applied magnets to auricular (ear) acupuncture points. The ear acupuncture points most often used were Shenmen, Kidney, Liver, and Occiput. Body and scalp acupuncture points were also stimulated, as were local and distal points in accordance with acupuncture diagnostic theory. The choice of acupuncture points varied depending on clinical indication.
Frequency and duration of magnet application
There was no standard protocol for frequency or duration of magnet application in the studies reviewed. In the case series, durations of application varied from 1-3 minutes (30) to near continuous wear for several years. (27;49) In the controlled trials, frequency of application varied from a continuous 72 hour wear to continuous 30 day wear with removal and replacement of magnets every 2-3 days.
Control devices and control groups
The most common sham control device used in the controlled trials was a non-magnetic needle or ear seeds, applied to the same points as the magnetic needles or magnets. Non-magnetised metal objects were also used as controls as were herbs and vitamins. Magnetic devices were sometimes applied to non acupuncture sites or non-magnetised discs to non-acupuncture sites.
Magnets as adjunct to standard care
Although not always specifically described as such, in more than half the studies, magnets appear to have been used as an adjunct to standard care. In some cases magnets were applied in addition to acupuncture needling, moxibustion or Chinese herbs. Magnets on acupuncture points served as an adjunct to standard care for diabetes management, (27;46) antihypertensive therapy, (26) antiemetic therapy (44;45) and antipsychotic therapy. (51) In studies of insomnia in the elderly, magnets served as a stand alone therapy. (52;54)
Adverse events
Adverse events included an exacerbation of hot flushes (24) and skin irritation due to the adhesives that held the magnets to the body. (52)
Discussion
Our goals in conducting this literature review were: 1) to summarise the outcomes and techniques of various acu-magnet intervention studies that have been published to date, primarily in English; and 2) to identify clinical conditions with positive outcomes, and assess whether a rigorous investigation of acu-magnet therapy for specific conditions is warranted. The most striking observation from this review was the overwhelmingly positive outcomes reported. A note of caution is that 34 of the 42 studies evaluated were conducted in China where there is a significant bias toward publishing positive trials." In addition, the studies were either case series or poor quality controlled trials, so no claims for the efficacy of acu-magnet therapy can be made at this time. Nonetheless, the large number of subjects (a total of 6453) in these studies suggests that many patients are treated with acu-magnet therapy in clinical practice, particularly in China, and report meaningful clinical improvement.
The single N of 1 study warrants special comment. (27) When evaluating clinical benefit for an individual patient, the N of 1 randomised controlled trial ranks highest in terms of evidence based hierarchy for that individual. An N of 1 controlled trial, involves the use of a crossover design to treat a single patient. In random order, the patient receives one period of active therapy and one period of placebo. The patient is kept blind to allocation, and treatment outcomes are monitored. In her N of 1 study, Chen used ear acu-magnet therapy, as an adjunct to standard care, to treat a patient with long standing diabetes mellitus. (27) The study looked at fasting blood glucose levels as the primary outcome measure. For seven days placebo discs were applied to the pancreas point of the left ear and the thalamus points of both ears. Then after a three day washout period, 2500G magnetic discs were applied to those same auricular acupuncture points. Results of this trial showed that fasting blood glucose during the placebo week was 194[+ or -]15mg/dL. During the active magnet week, fasting glucose dropped to 136[+ or -]10mg/dL. Having determined that auricular magnets applied to this patient using this dosing regimen were effective, the clinician researcher then used magnetic ear clips for ongoing treatment as an adjunct to standard diabetes management. At four year follow up, evaluation of this patient showed a persistent decrease in fasting blood glucose and HbAIC with no further progression of the patient's diabetic neuropathy.
We believe that the preliminary evidence for two conditions, insomnia in elderly patients (52;54) and glucose control in diabetics, (27) justify further clinical trials to evaluate the effectiveness of acu-magnet therapy. The studies of Suen et al (52;54) and Chen 21 should be replicated as the first step in this program of research on acu-magnet therapy.
Information gained from this review will help to guide protocol development for future studies. Of particular relevance to future trials is the fact that adverse reactions associated with acu-magnet therapy were reported in only two studies. In one study, high intensity magnets (surface field strength ~2000G) were left on six clinically 'powerful' acupuncture points for 72 hours, to treat hot flushes. (24) Participants in this study had an exacerbation of their hot flush symptoms. An important lesson learned is that dosing parameters such as number of acupuncture points to treat simultaneously, the strength of the magnet and duration of magnet application should be tested and optimised prior to conducting a clinical trial. Skin irritation associated with the adhesive securing the tape may need to be considered when adverse reactions are encountered.
Acu-magnet therapy research shares many of the methodological challenges faced by acupuncture research in general. At a minimum, a rationale for acu-point selection and style of acupuncture used, need to be justified. Acupuncture points might be selected for a number of reasons including: following traditional Chinese medicine theory or Japanese style acupuncture or treatment of ah shi or trigger points, or using one of the acupuncture microsystems such as Korean hand acupuncture, scalp acupuncture or auriculotherapy. The acupuncture points should be described with the standard nomenclature of the World Health Organisation. (68)
Specifics of treatment, including the magnetic device itself (material composition, strength, dimensions and polarity) and the SMF dosing regimen should be detailed. The exact dosing regimen should include the site and method of magnet application, and frequency and duration of application. The dosing regimen should be pretested, optimised and precisely documented. We discovered in this review that the most lasting beneficial effects were associated with long term magnet use. (27;28;49;55) When magnets are applied for a prolonged time period or when patients self-apply magnets, the small magnetic discs may be secured to the skin via earrings or clips (in the case of auricular points) or sewn into a garment to be worn over the acu-point. If, on the other hand, high intensity magnets are applied during an in-office treatment, the method of application may be a needle, a stronger magnet or perhaps an electromagnetic device.
Polar configuration of the magnet(s) used is a special concern in the acupuncture paradigm as acupuncturists may use north and south poles on a pair of acupuncture points to either 'tonify' or 'disperse'. Terminology used to describe the poles of magnets is confusing in the literature. The term bionorth is used by some clinicians to describe what physicists denote the south pole of a magnet, ie the side of the magnet that attracts the south seeking needle of a compass. For clarity of meaning and consistency of reporting, we recommend that authors state which pole faced the skin and then define that pole with reference to a compass and/or a geographic pole. For example, one might report 'we applied the 'north' pole of the magnet to the skin and we define the 'north pole' as that side of the magnet that attracts the north seeking compass needle.' Or researchers might also report, 'When suspended by a string, the side of the magnet that faced the skin orients itself to face the earth's geographic south pole'.
Blinding subjects in acu-magnet therapy trials is problematic because magnetic properties are readily detected, making it easy for trial participants to deliberately or unintentionally discover whether their device is magnetised or not. We may not be able to use low strength magnets as sham controls because we still do not know the minimal effective dose of SMF therapy. Effects have been reported with magnets having field strengths as low as 66G. (55) Another potential control device used in some studies is semen vaccariae, a small seed which the investigators assumed to have no therapeutic effect as long as no pressure was applied to it, semen vaccariae, however, is considered a significant blood 'vitaliser' by Chinese herbalists, which may preclude its use as a sham control. Non-acupuncture sites may also be used as sham controls; however, many so-called 'sham points' have a physiological effect when stimulated with a needle. It is unclear whether or not a SMF placed anywhere on the skin might also have an effect.
Strengths and limitations of this review
The primary strength of our literature review is that it organises and summarises the available literature on acu-magnet therapy. No previous reviews of the acu-magnet literature have been conducted. Another strength is our sampling of related Chinese language literature. The limitations pertain to being unable to access other language literature, especially Japanese. Acu-magnet therapy is commonly practised in Japan. We also acknowledge the limitation of having no access to EMBASE, an electronic database where much of the European literature is found. We consider this project a first step toward developing a more rigorous program of research into acu-magnet therapy.
Future directions
This review has generated a number of questions to be answered in future clinical trials. These questions are summarised in Table 6. We recently initiated a small pilot study in an attempt to replicate Chen's findings of improved glucose control in diabetic patients with the use of ear acu-magnets (27) Our study intends to evaluate the use of non-magnetized pellets as sham controls. We will assess a dosing regimen of between 3-5 magnets (800G surface field strength, north pole facing the skin) applied for a one week period. If our findings show promise we will move forward with a full scale randomised controlled trial using magnets and sham controls to assess the efficacy of acu-magnet therapy as an adjunct to standard care for Type 2 diabetes mellitus. If our findings are negative we will conduct another pilot study using an alternate SMF dosing regimen.
Conclusions
In the absence of any consistent terminology we coined the term acu-magnet therapy to describe the application of magnets on acupuncture points as a distinct modality. We believe that further investigation of acu-magnet therapy as an adjunctive treatment for diabetes and for insomnia in the elderly is warranted based on findings from this review. Future trials should be rigorously conducted according to STRICTA (69) and CONSORT (70) guidelines, while paying special attention to the unique methodological and dosimetry issues associated with static magnetic field therapy. (9) The overall poor quality of the studies in this review precludes any evidence based treatment recommendations at this time.
Conflict of interest
The authors report no conflict of interest with any of the material presented in this manuscript.
Sources of Support
This study was funded in part by the National Center for Complementary and Alternative Medicine, National Institutes of Health (R21 AT003293).
Summary box
Many practitioners apply magnets to acupuncture points as
therapy
This study systematically reviewed all the available clinical
trials
37 out of 42 studies reported therapeutic benefit of
magnets
The quality of the evidence is not sufficient to make
treatment recommendations
The positive findings are sufficiently interesting to justify
further research
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