Practice of Acupuncture E-Book

Hans Ulrich Hecker

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 608

Veröffentlichungsjahr: 2004

Beschreibung

Combining the principles of Traditional Chinese Medicine (TCM) with Western medical acupuncture, this eagerly awaited book and CD-ROM brings the entire field of acupuncture to a new professional standard. The authors, leading experts from diverse disciplines, systematically guide you through the channels, point locations and trigger points in the body, from head to toe. Each acupuncture point is shown in vivo and then explained in detail, using illustrations that show its exact anatomical location and characteristics.

In addition, you will benefit from state-of-the-art information never published before, including: a universal point localization system based on anatomic principles; a comprehensive discussion of potential contraindications and side effects of acupuncture; and a focus on outcome-based models and scientific studies throughout.

Ideal for those who practice Traditional Chinese Medicine as well as anyone studying for certification, this book covers all acupuncture point locations, as well as the fundamental concepts and methods of this ancient art. It is indispensable for practitioners who need the most complete, scientifically based, and reliable information available anywhere.

Leseprobe

The Authors

Hans-Ulrich Hecker, M.D.

Medical specialist in general medicine, acupuncture, naturopathy, and homeopathy. Lecturer in Naturopathy and Acupuncture, University of Schleswig-Holstein, Germany. Research Director of Education in Naturopathy and Acupuncture, Academy of Continuing Medical Education of the Regional Medical Association of Schleswig-Holstein.Certified Medical Quality Manager.Assessor of the European Foundation of Quality Management (EFQM).e-mail:[email protected]

Angelika Steveling, M.D.

Chiropractor, NLP practitioner.Head of the Department of Traditional Medicine at the Institute for Radiology and Microtherapy, University of Witten-Herdecke, Germany.Lecturer for Acupuncture Continuing Education, Regional Medical Associations of Schleswig-Holstein and Westphalia-Lippe.Lecturer of the German Society of Physicians for Acupuncture (DÄGFA).e-mail: [email protected]

Elmar T. Peuker, M.D.

Medical specialist in general medicine, anatomy, chiropractic, and naturopathy.Lecturer for Acupuncture and Naturopathy Continuing Education, Regional Medical Association of Schleswig-Holstein. Diploma in Health Economy.Head of the Complementary Medicine Study Group, Department of Anatomy, Wilhelm University of Westphalia, Muenster, Germany.Lecturer at the British Medical Acupuncture Society (BMAS), UK.e-mail:[email protected]

Joerg Kastner, M.D.

Training in internal medicine, sports medicine, and naturopathy. Head of Acupuncture at the Academy of Continuing Medical Education of the Regional Medical Association of Westphalia-Lippe.Founder and Medical Director of the Academy for Acupuncture and Traditional Chinese Medicine (afat), Bavaria. Guest lecturer at Guangxi University, China. Practitioner of naturopathy, homeopathy, sports medicine, TCM, and nutritional therapy in a joint practice in Wessling, Bavaria.e-mail:[email protected]

Collaborators

Professor Timm J. Filler, M.D.

Clinical Anatomist, Head of the Clinical Anatomy Division, Department of Anatomy, University of Muenster, Germany.e-mail: [email protected]

Lei Zhang

Department of Traditional Medicine, Institute for Radiology and Microtherapy, University of Witten-Herdecke, Germany.

Professor Dietrich H. W. Groenemeyer, M.D.

Director of the Institute for Radiology and Micro-therapy, University of Witten-Herdecke, Germany.

Practice of Acupuncture

Point Location–Techniques–Treatment Options

Hans-Ulrich Hecker, M.D., L.Ac.

Physician in Private Practice Kiel, Germany

Angelika Steveling, M.D., L.Ac.

Physician in Private Practice Essen, Germany

Elmar T. Peuker, M.D., L.Ac.

Clinical Anatomist Physician in Private Practice Muenster, Germany

Joerg Kastner, M.D., L.Ac.

Physician in Private Practice Wessling, Germany

With the collaboration of:

Timm J. Filler, Lei Zhang, Dietrich H.W. Groenemeyer

897 illustrations195 tables

ThiemeStuttgart • New York

Library of Congress Cataloging-in-Publication Data is available from the publisher

This book is an authorized and revised translation of the 2nd German edition published and copyrighted 2002 by Hippokrates Verlag, Stuttgart, Germany. Title of the German edition: Lehrbuch und Repetitorium—Akupunktur mit TCM-Modulen

Translator: Ursula Vielkind, Ph.D., C. Tran., Ontario, Canada

To our children:

Antje, Esther, Finn-Mathis, Gerrit, Janna, Karen, Levin, Luisa, Lynn-Christin, Max, Ole, Thies

© 2005 Georg Thieme Verlag,Rüdigerstrasse 14, 70469 Stuttgart, Germanyhttp://www.thieme.deThieme New York, 333 Seventh Avenue,New York, NY 10001 USAhttp://www.thieme.com

Cover design: Martina Berge, ErbachTypesetting by wunderlich-design, KielPrinted in Germany by Appl, Wemding

ISBN 3–13–136821–7 (GTV)ISBN 1–58890–244–7 (TNY)       1 2 3 4 5

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed.

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

Foreword

The safe and competent practice of acupuncture requires of practitioners that they follow several principles. First and foremost, they should either make, or seek from a suitably qualified practitioner, an orthodox medical diagnosis prior to the application of acupuncture since symptomatic relief from acupuncture may delay the diagnosis of serious disease. Secondly, an appropriate risk–benefit assessment regarding the use of acupuncture should be made in partnership with the individual consenting to treatment. This text includes a comprehensive section on the potential adverse events related to acupuncture, including comments on indirect risk.

Thirdly, the practitioner should use appropriate procedures to minimize the risk of transmission of infections that may result from the application of acupuncture and related techniques. Finally, the practitioner should apply acupuncture, and its related techniques, with due care of anatomy so as to minimize the potential for traumatic adverse events. This text includes anatomical details for all the channel and extra points, and describes where necessary potential adverse events related to individual points. Surprisingly, this is one of the few texts that specifically comments on anatomical hazards, and for that reason alone it can be highly commended.

As well as following these principles, competent practice requires the practitioner to follow a consistent and evidence-based model, so that audit and research of practice can inform application of, and modifications to, the model. Across the globe there are numerous different models or styles of practice within the field of acupuncture. Most styles include, to a greater or lesser extent, elements of Traditional Chinese Medicine (TCM). In several Western countries these elements of traditional acupuncture have been selected and modified to fit a cultural niche and a perceived need. In the UK, the majority of health professionals use a Western approach that retains only the most useful classical points (although some have even dispensed with the notion of points) and principally selects sites for treatment based on segmental innervation or the presence of myofascial trigger points. This may be because of science, iconoclasm, or the time pressures of the National Health System. But whatever one’s particular approach to therapy, it is often useful to have a reference text that illuminates some of the rather esoteric links made between the soma and bodily functions in TCM. This text includes a considerable element of such links, both within the main section on specific acupuncture point location and anatomy as well as in a separate section. There are many books describing TCM theory, and they are often rather impenetrable to the uninitiated reader. The relevant section in this text is remarkably easy to dip into by virtue of the many graphical illustrations, diagrams, and charts. It is so visually appealing that it may even encourage strictly orthodox characters like myself to occasionally browse through some traditional concepts.

The authors are to be congratulated on producing a very comprehensive text that will be useful to the vast majority of acupuncture practitioners, whatever their particular models of practice.

Fall 2004, London                         Mike Cummings

Preface

This practical tutorial is a multi-functional book.

The authors, who have been involved in acupuncture training for many years and who are aware of the difficulties of conveying the material, have put their international teaching experience into practice here.

Besides detailed representation of all the body acupuncture points, the reader will find a tutorial for the most important points that, for the first time, provides universal point localization on an appropriate anatomical structure. This is not an end in itself but serves as a fast and reliable aid to orientation for the beginner as well as the advanced student.

This localization of acupuncture points is more reliable and precise than localization according to the relative Cun measures. Investigatory methods taken from chiropractic therapy, which facilitate the search for acupuncture points, have been taken into consideration and supplement the descriptions.

A further innovative aspect is the introduction of a color-coded index. This provides effective access to the necessary information, in line with daily practice. For the reader this means no more annoying and time-consuming consultation of the list of contents. The search for specific acupuncture points can be carried out accurately according to various search criteria.

The authors have put special emphasis on conveying seemingly difficult teaching content. Thus, the basic principles of Chinese Medicine are presented here according to a system developed by the authors.

The frequently unstructured listing of individual symptoms used in previous books has been eliminated. Instead major symptoms are defined and learning is facilitated considerably by highlighting the differences and comparing, for example, individual syndromes. Meanwhile, in Germany the visual didactic processing system (VISDAC) defined by the authors has become an accepted seal of quality and guarantee of learning success.

A special, detailed chapter deals with the contraindications and side effects of acupuncture. The latest scientific studies have been taken into consideration and surely represent a new phenomenon in this form. We consider this essential within the framework of quality development and taking into account forensic points of view.

Our aim, which we would also like to bring across in this book, is to create quality standards in acupuncture.

We hope that our multi-functional book helps our readers to get to the point quickly, reliably, and efficiently when learning about acupuncture and the basic principles of Chinese Medicine.

We should like to thank all those who have been involved in the production of this book.

Mr. Rüdiger Bremert for his excellent anatomical drawings, Mr. Axel Nikolaus for the photography, and Mr. Martin Wunderlich for the professional graphic design.

Our special thanks go to Ms. Angelika-Marie Findgott whose great personal commitment and specialist knowledge made possible the translation of this standard tutorial and its international distribution.

Kiel, Essen, Münster, Weßling

Contents

Basic Theory of Acupuncture

Scientific Aspects of Acupuncture

Indication and Direction of Action of Acupuncture

Relative Contraindications

Excessive Reactions, Undesired Effects, and Complications

Yin and Yang

Qi

The System of Channels

The Channel Clock

The Five Phases of Transformation

Acupuncture Points

Characteristics of Acupuncture Points

Localization of Acupuncture Points

Method of Needling

Needle Stimulation

Moxibustion

Cupping

Differentiation of Acupuncture Points—Control Points

Side Effects of Acupuncture

Introduction to the Subject

Delay in the Diagnosis of a Disease

Worsening of a Disease as a Result of Treatment

Autonomic Reactions

Infections

Accidental Damage to Organs and Tissues

Other Side Effects

Cun Measurement

How to Locate Acupuncture Points

Proportional Measurement Based on Body Cun

Proportional Measurement Based on Finger Cun

The Channels

The Lung Channel (LU) (Hand Tai Yin)

The Large Intestine Channel (LI) (Hand Yang Ming)

The Stomach Channel (ST) (Foot Yang Ming)

The Spleen Channel (SP) (Foot Tai Yin)

The Heart Channel (HT) (Hand Shao Yin)

The Small Intestine Channel (SI) (Hand Tai Yang)

The Bladder Channel (BL) (Foot Tai Yang)

The Kidney Channel (KI) (Foot Shao Yin)

The Pericardium Channel (PC) (Hand Jue Yin)

The Triple Burner (San Jiao) Channel (TB) (Hand Shao Yang)

The Gallbladder Channel (GB) (Foot Shao Yang)

The Liver Channel (LR) (Foot Jue Yin)

The Conception Vessel (CV) (Ren Mai)

The Governor Vessel (GV) (Du Mai)

The Extra Points (EX)

Topography

Important Points in the Frontal Region of the Head

Important Points in the Lateral Region of the Head

Important Points on the Top of the Head

Important Points in the Neck Region

Important Points in the Posterior Region of the Shoulder

Important Points in the Anterior and Lateral Regions of the Shoulder

Important Points in the Elbow Region

Important Points in the Regions of the Hand and Forearm

Important Points in the Frontal and Lateral Regions of the Chest

Important Points in the Posterior Region of the Chest

Important Points in the Abdominal Region

Important Points in the Lumbar Region

Important Points in the Hip Region

Important Points in the Anterior and Medial Regions of the Knee and Lower Leg

Important Points in the Posterior and Lateral Regions of the Knee and Lower Leg

Important Points on the Dorsum of the Foot

Important Points in the Medial Region of the Foot

Important Points in the Lateral Region of the Foot

Refresher: Points for TCM Syndromes

Important Points Arranged According to TCM Syndromes

Pragmatic Five-Step Concept for Treating Locomotor Pain and Headaches

Diagnostic Step One: Excess–Deficiency

Diagnostic Step Two: Channel–Axis

Treatment of Headaches

Treatment of Pain in the Neck and Upper Thorax

Treatment of Pain in the Shoulder

Treatment of Pain in the Elbow

Treatment of Lumbago

Treatment of Lumbago–Sciatica

Diagnostic Step Three: Dysfunctional Muscles

Diagnostic Step Four: Pattern of External Pathogenic Factors (Climates)

Diagnostic Step Five: Internal Pathogenic Factor (Emotion) and Pattern of Zang Fu Disharmony

Pragmatic Five-Step Concept for Treating Internal Diseases

Diagnostic Step One: Differentiation According to the Eight Principles (Ba Gang)

Diagnostic Step Two: Pattern of Disharmony According to the Zang Fu Organs

Diagnostic Step Three: Pattern of Disharmony According to Internal Pathogenic Factors (Emotions)

Diagnostic Step Four: Pattern of Disharmony According to External Pathogenic Factors (Climates)

Diagnostic Step Five: Specific Dysfunctions

An Example of Treatment in Compliance with the Pragmatic Therapeutic Concept: Chronic Gastritis Associated with Cold and Dampness

TCM: Identifying Patterns of Disharmony

Introduction

Patterns According to the Eight Principles (Ba Gang)

Patterns According to the Internal Organs (Zang Fu)

Patterns According to External Pathogenic Factors (Five Climates)

Patterns According to Internal Pathogenic Factors (Five Emotions)

Patterns According to the Vital Substances (Qi, Blood, Essence)

Concluding Comments—Case Studies

Psychosomatic Dysfunctions

Basic Therapeutic Concept for Psychosomatic Dysfunctions

Mind–Body Relationships of the Organ Networks According to TCM

The Lung Network

The Kidney Network

The Liver Network

The Heart Network

TCM Refresher

Basic Information on TCM

Formation of Qi

Formation of Blood (Xue)

The Five Functions of Qi

Flow of Qi in the Zang Fu Organs: Physiology and Pathology

Main Symptoms of Disturbed Organ Networks

Basic Patterns of Zang Fu Disharmony

Patterns of Disharmony According to Ba Gang (Deficiency, Excess, Heat, Cold)

Symptoms of Basic Patterns of Disharmony

Differentiation Between Yang Deficiency and Yin Deficiency

Differentiation Between Qi Deficiency and Blood Deficiency

Differentiation Between Qi Deficiency and Qi Stagnation

Differentiation Between Patterns of the Blood (Deficiency, Stasis, Heat)

Differentiation Between Patterns of Deficiency (Yang, Yin, Qi, Blood)

Differentiation Between Qi Deficiency of the Lung, Spleen, and Heart (Kidney)

Differentiation Between Yang Deficiency of the Spleen, Kidney, and Heart

Differentiation Between Yin Deficiency of the Kidney, Lung, and Heart (Liver)

Differentiation Between Blood Deficiency of the Heart and Liver

Differentiation of Pain Associated With External Pathogenic Factors

Differentiation of Pain Associated With Qi Stagnation and Blood Stasis

Changes of the Tongue Assigned to Patterns of Disharmony

Zang Fu Patterns of Disharmony in the Modular System—Three-Step Comparison of the Main Patterns of an Organ Network

Zang Fu Pattern of Disharmony in the Modular System: The Lung

Zang Fu Pattern of Disharmony in the Modular System: The Heart

Zang Fu Pattern of Disharmony in the Modular System: The Spleen

Zang Fu Pattern of Disharmony in the Modular System: The Stomach

Zang Fu Pattern of Disharmony in the Modular System: The Liver

Zang Fu Pattern of Disharmony in the Modular System: The Kidney

Appendix

References

List of Points in Alphabetical Order

Subject Index

To access additional material or resources available with this e-book, please visit http://www.thieme.com/bonuscontent. After completing a short form to verify your e-book purchase, you will be provided with the instructions and access codes necessary to retrieve any bonus content.

Basic Theory of Acupuncture

Scientific Aspects of Acupuncture

Indication and Direction of Action of Acupuncture

Relative Contraindications

Excessive Reactions, Undesired Effects, and Complications

Yin and Yang

Qi

The System of Channels

The Channel Clock

The Five Phases of Transformation

Scientific Aspects of Acupuncture

The following sections mainly deal with four topics. The first sections provide some background information and then describe the requirements for scientific studies in acupuncture. The remaining sections deal with pain and with anatomical correlates of acupuncture points.

Background

Western and Eastern (traditional Chinese) medicine are the only systems of medicine that have become global in the 20th century and have established themselves intensely in other culture areas. This has created some tensions, primarily in the West, prompting more and more scientists oriented toward Western methods to attempt a resolution. Acupuncture (Latin: acus, needle) was mentioned for the first time in 90 BC in the twin biography of the traveling physician Bian Que and the Han physician Chunyu Yi in the classic Shi Ji (The Historical Records) [Unschuld, 1997].

Gold, silver, or steel needles are inserted into empirically defined points where they penetrate the patient’s skin to various depths, in order to achieve a therapeutic effect in different organs and functional systems. According to the underlying Eastern philosophy, the needle treatment can be used to influence the movement of life force or energy (qi) in channels (or meridians).

Traditionally, acupuncture was combined with the burning of dried mugwort (moxibustion or moxa)—which is expressed in the originally term, zhen jiu (puncture and burning). Today, other methods of needle stimulation are used in addition to moxibustion, for example, electrostimulation and cupping.

Pain relief through acupuncture was developed in modern China after 1945 under the initial influence of Western medicine. At the end of the 1950s, the French physician Paul Nogier developed the method of auriculotherapy, or ear acupuncture, which is used for both therapy and analgesia.

The cultural background of a therapy may create a fundamental conflict. This problem not only exists for patients (and their expectations) but also for therapists (and their ability to immerse themselves in other cultures and their ways of thinking). Depending on the culture, the approach to both diagnosis and therapeutic procedure may differ considerably due to different schools of thought and previous knowledge, and also due to a therapist’s individual way of dealing with patients—which again is influenced by the particular environment. On the other hand, the patient’s expectations play a major role. This not only refers to the full spectrum of rejection–doubt–endorsement–conviction, but also to ideas of how the therapist should behave in the eyes of the patient. Furthermore, the patient may have heterogeneous wishes that he or she normally does not communicate. The patient may want to have a Western diagnosis and an Eastern therapy, or an Eastern diagnosis but only an adjuvant therapy. Many different scenarios can be envisioned here. Thus, it is not without problems to transfer a therapeutic method from one culture to another without adapting it. Once it has been transferred, it begins to undergo its own evolution.

Placebo Effect

In 1976, the Western world received its first important impulse for genuine basic research in the field of acupuncture through the hypothesis that the acupuncture effect is mediated by the endorphinergic system [Stux and Pomeranz, 1987]. This system consists of neurons located mainly in the mesencephalon (raphe nuclei and central gray substance). Its analgesic effect is mediated by the release of endorphins (neurotransmitters with a morphine-like action) via the reticulospinal tract. Up until this point, the general view in science had been that placebo effects were the main basis of this therapy [Beecher, 1955]. In other words, the method would only be effective because the persons treated (and their therapists) would firmly believe in it. Furthermore, the effects achieved were partly regarded as nonspecific. However, this view ignored the results of studies involving either animal experiments or acupuncture effects in children, which could not be explained by the classic placebo mechanism. In adults, psychological studies investigating the suggestibility of patients also seemed to indicate that specific effects played an important role.

Rather than making the general assumption that we are dealing with a placebo effect, it is more meaningful to search for an effect in connection with the disease so that the modality can be applied more specifically and, if possible, without acupuncture. For example, there are numerous speculations on better recovery from stroke under the influence of acupuncture. It is not clear, however, whether or not this should be attributed to the fact that the patient receives additional interest and far more attention [Park et al., 2001; Vickers et al., 2002]. Acupuncturists typically spend more time with their patients than conventional physicians. It is important to differentiate between this effect, the aura of Eastern mystique, and the substantial influence of the needle treatment itself. In doing so, it is helpful to distinguish between short-term and long-term treatment, because the success of acupuncture is not always so impressive for long-term treatment.

For a long time, published records of studies on the positive effect of acupuncture were only of illustrative character. The case-study character is quite acceptable when reporting undesired effects. Despite the remarkably extensive database of case studies, however, skepticism towards such material—compared with controlled clinical studies—is valid if the study is supposed to demonstrate the therapeutic effects. While “serious” scientists have regarded the involvement with this subject as obsolete and as an interference with one’s career, many practitioners have shown only half-hearted ambition to separate reality from mystique. Meanwhile—at least since there has been noticeable public support—there is a certain stimulus to tackle the subject scientifically and to raise the standards of the basic scientific data. There are only a few Western specialists today who reject acupuncture completely, and this is largely due to the successful alleviation of pain. Only the underlying mechanism of the effect remains a bone of contention. As a consequence of this process, demands that acupuncture should be included in the curriculum of medical students are increasing, and plans have already been put to action at some locations [Rampes et al., 1997]. For the time being, however, this dynamic development carries the considerable risk of self-declared “experts” getting involved in the uncritical and unqualified transfer of knowledge.

Scientific Studies

“Despite intense research nobody has provided any convincing scientific evidence that the channels or the ‘flow of energy’ do exist” [White, 1998]. So far, research findings of Western standards make it very unlikely that acupuncture acts by treating diseased organs directly. Rather, the influence is indirect, with the brain obviously intervening by means of neuronal and chemical (hormonal) activities. It is especially the connection between brain function and acupuncture that has been ignored by classic Eastern medicine. More recent studies have prepared the ground for a far-reaching conceptual understanding. There is a constant relationship between disease-related acupuncture points and the corresponding brain areas (instead of, or supplementing, the relationships between the indication for acupuncture points and more or less abstract causes). This comes much closer to the Western sense of plausibility than do any Eastern ideas [Cho et al., 1998]. It should be noted in this connection that the results of studies on the effectiveness of a method are often culturally tinted. Interestingly, an increasing number of meta-analyses on the comparability of studies or their scientific quality can be found in the literature, especially for acupuncture. This must be understood as an expression of the attempt to clarify why the Western and Eastern models of explanation are partly incompatible. For example, in 1998, a comparison of studies on the effectiveness of acupuncture in treating nausea and pain showed that the effectiveness is up to 100% in Far-Eastern studies, about 50% in US studies, and less than 20% in European studies.

Apart from extensive case descriptions, there are numerous studies with seemingly sensational results that, in scientific circles, sometimes bring discredit upon the procedure rather than promote it. In these cases, it is worth having a look at the size of patient groups or at the method and its reproducibility prior to accepting the results. Time and again, general statements are spread by certain media only because they have been published—and this has not necessarily been the intention of the authors.

Requirements

Typical weaknesses and errors in the approach of previous studies have been that:

1. The number of patients was too small

2. The selection criteria were not sufficiently diversified

3. The group assignments were not randomized

4. The study was not double blind

5. There was no standardized protocol of investigation

6. The study was not prospective

7. There were insufficient statistical methods, or none at all

8. There were inaccurate or insufficient details, or none at all, on the parameters for measuring the results or for demonstrating the therapeutic success, or evaluation of the findings was purely subjective

9. The study used untrained acupuncturists (no qualification and certification of the therapists)

10. There was no follow-up and investigation of long-term effects versus short-term effects.

These limitations prevent targeted, effective, structured, and well-designed processing of the available data and further development of the acupuncture method. Therefore, the sometimes spectacular applications, such as open-heart surgery under acupuncture analgesia [Hollinger et al., 1979], cannot be evaluated and repeated reliably, although one can suspect that there is a remarkable, not yet exhausted, potential in the application of acupuncture, and that this potential could be developed.

For a clean study, therefore, some preconditions must be met. These include:

• A large enough number of patients

• A control group

• Randomized assignment to the groups of the study

• Double-blind study design (neither therapist nor patient know the group assignment)

• Prospective study design

• Placebo needles.

Control groups usually create a problem. Different procedures are used for obtaining such groups of comparison for a study:

1. Acupuncture versus no treatment: This approach is not always ethical, or does not apply to all treatments. Furthermore, the treatment group is subjected to at least two influences (acupuncture and therapist) so that the effects obtained cannot be unambiguously assigned in comparison with the control group. These are not double-blind studies

2. Acupuncture versus mock acupuncture (by needling nonacupuncture points): It has not been demonstrated that the prerequisite for this procedure (the needling of nonacupuncture points) has no effect. In some such studies, points are used as nonacupuncture points even though they may have a specific effect on the disease being investigated [Linde et al., 2000]. In addition, the patient may be able to recognize his/her assignment to a particular group. Thus, this is not a double-blind study either

3. Specific acupuncture versus acupuncture for a different disease: Uncontrollable cross-effects may be possible. Again, there is no way of performing a double-blind study

4. A combination of the previously mentioned procedures: This type of study becomes more confusing, is prone to errors, and falsely suggests that systematic errors, such as the previously mentioned ones, are minimized or neutralized

5. Acupuncture with placebo needles: The essential advantage here is that the patient doesn’t know whether or not he/she has been needled. Blind studies are possible.

In 1998, Konrad Streitberger and colleagues at the University of Heidelberg, Germany, developed a placebo needle that allows for better control groups [Streitberger and Kleinhenz, 1998]. This needle is pressed onto the skin like a true needle, but then slides back into its case rather than underneath the skin. The patient perceives a puncture without the needle having penetrated the skin. In this way, psychological effects that might cause faster healing can be minimized. Initial investigations have demonstrated that acupuncture does have specific effects [Kleinhenz et al., 1999]. Critics such as Ted Kaptchuk of Harvard Medical School believe that this method of investigation still doesn’t go far enough, because double-blind studies are not quite possible. In case of the Streitberger needle, the therapist knows whether he/she uses a true needle or a placebo needle. Park et al. [2001] and Peuker et al. [2002] developed similar needles with the objective, among other things, to blind the therapist as well.

Another important prerequisite, apart from adequate control groups, is that effects can be measured objectively. The following criteria are important:

1. Measuring the blood flow in areas of the brain by means of functional magnetic resonance imaging (MRI) or transcranial Doppler (TCD) ultrasound

2. Comparisons of the durations of events (e.g., uterine involution, speed of cervical dilation). Important differences in studies on acupuncture concern aspects of time:

• Do the results show short-term or long-term effects?

• How often should needling be performed?

• How quickly do effects occur?

3. Number of events

4. Quantifiable parameters (e.g., amount of milk produced)

5. Visual analog scale (e.g., subjective evaluation of pain)

6. Electrophysiological recording of the neuronal activity in peripheral nerves or the spinal cord, possibly under the influence of well-known substances that have a modulating influence on neuronal activity.

One argument that is often put forward states that the Western system of assigning or classifying diseases does not correspond to the Eastern system; as a result, therapies are applied that would not have been suggested by Eastern diagnosis. For studies, however, this Western assignment is established precisely for reasons of comparability so that the key demand of every scientific study—reproducibility—can be met. Critics of such studies vehemently point to the strong individuality and patient-specificity of acupuncture, which would not be possible if the procedure were standardized. Standardization would ignore too many symptoms of diseases, thus yielding false group affiliations. On the one hand, there is no convincing evidence for the Eastern working hypotheses, that is, what should be investigated would be already introduced into the study as a prerequisite. On the other hand, it is true that the Western approach does not cover many symptoms that can be used for differentiation. This escalation of conditions is partly based on ideology and can quickly block any conceptualization of a study protocol that is supposed to make the results verifiable and reproducible. Neither total individualization nor (partial or complete) disregard of the theoretical concepts of acupuncture make it possible to establish more reliable results, which would lead to a better recognition of acupuncture as an equivalent therapeutic procedure. But without supplementing individual case studies with studies according to scientific standards, no improvement is possible. The way out of this dilemma is to increase the number of patients. In order to achieve high comparability and usability of the data, centralized and controlled multicenter studies are a possibility. Popular research areas in acupuncture from the Western point of view are currently:

• Pain management

• Psychiatry, drug and medication abuse, quitting smoking (these aspects of treatment options have received attention increasingly since about 1980)

• Anatomy and imaging procedures

• Cardiology

• Gynecology

• Ear acupuncture

• Dentistry.

So far, however, none of the available theories sufficiently explains what happens during acupuncture. For that reason, acupuncture still is a purely empirical method that cannot fully meet the growing scientific demands of medicine. One should investigate not only its effects, but also the hypotheses for its mechanism of action. Some studies suggest that there are functional points that act in every person. These studies show that standardized point combinations yield results in many patients. This would put into perspective the individual selection of points for each patient as demanded by the Chinese approach. In fact, treatment plans are used fairly often in practice.

Pain

Meanwhile, there are plenty of useful publications on the modulation of pain with acupuncture [Pomeranz and Strux, 1989; Ernst and White, 1999; Vickers et al., 2002]. For example, various ideas have been developed in animal models about the possible neuronal mechanisms of action. However, these explanations are really of limited value because the understanding of such systems is still incomplete. This is particularly true as today’s basic research is above all focused on molecular and cellular mechanisms, which are easier to find out, whereas interactions on the level of tissues or organs find less attention due to the lack of suitable tools. The following aspects of pain management with acupuncture are currently being investigated:

• Effects on central neurotransmitter systems (serotoninergic system, catecholaminergic system, endorphinergic system, encephalinergic system, substance P system, and their interactions), i.e., mainly systems that inhibit pain

• Effects on nerve regeneration

• Effects on local blood flow, which has a decisive influence on the production and local elimination (washout) of pain-inducing substances at the site of injury.

Gate Control Theory, Trigger Points, and Neuromatrix of Pain

An earlier neurophysiological attempt of explaining the effect of acupuncture on pain was the Gate Control Theory [M elzack and Wal l, 1965]. It described pain modulation of sensory impulses by inhibitory mechanisms in the central nervous system (CNS). According to this theory, the acupuncture prick is thought to excite the rapidly conducting sensory nerve fibers of the affected skin or muscle regions, whereby the impulses of these fibers overtake in the spinal cord the impulses of more slowly conducting fibers from the diseased organs. In this process, inhibitory interneurons are activated that have an effect on the slower conducting pathways. The therapeutic use of counter-irritation has been “discovered” by scientists more than once. This concerns those paradox, pain-reducing effects that alleviate pain by means of pain through heterotropic stimulation of body areas. This often interrupts a vicious circle and achieves a lasting effect, thus providing the opportunity for regeneration as long as the injury has not yet become irreversible.

One of the oldest methods of reducing pain is the stimulation of myofascial trigger points, either by acupuncture, or by cold, heat, or chemical irritation of the skin. The principle here is: “intense over moderate” sensory perception, a kind of analgesia based on overstimulation. It is applied over the affected site or sometimes also at a distance from it. A brief, painful stimulus can cover up chronic pain for a long time or even permanently. According to our understanding of central nervous processes today, an unconscious autonomous reaction occurs in the pain-processing centers of the brain stem, on the one hand, and a modification of the conscious perception in the cortical fields of the cerebrum, on the other [Melzack, 1981]. In addition to the ascending impulses, the pathways that descend from the cerebral cortex to the spinal cord also activate inhibitory interneurons. The responsible transmitters in the brain and spinal cord are often pain-inhibiting endogenous opiates. Furthermore, recurrent neuronal activities induced by chronic pain are possibly interrupted. Local injection of anesthetics, overstimulation, or surgical interruption of pain conduction are comparable methods.

The explanations above stem from early attempts to understand the complex central connections—and acupuncture’s effects on them—mainly in the context of a cybernetic interpretation of how the brain functions. Among other things, these attempts have overlooked the possibility of plastic reactions [Wiener, 1972; Takeshige, 1985]. Whereas acute pain has been painstakingly investigated, chronic (so-called serious) pain syndromes—which may not be associated with any injury or pathology—remain mysterious. Furthermore, the frequently observed relationship of these syndromes to emotional or physical stress is not yet sufficiently understood.

More recent theories assume that the sensation of pain is a multidimensional experience that has its origin in the fact that nerve impulses create identifiable patterns, or neurosignatures, by means of an extensive neuronal network, the neuromatrix. The neuronal network thus forms an image of the body. The neurosignatures for the sensation of pain are typically induced by sensory input, but they can also be activated without this trigger. The neuromatrix theory represents a conceptional framework for the investigation of problems associated particularly with chronic pain syndromes. It assumes that the respective neuronal image of the body activates programs that influence perception, self-perception, behavior, and homeostasis with all its mechanisms. This applies to every pathology, inflammation, injury, or type of chronic stress. Pain therefore results not so much from a direct sensory event but more from the activity of an extensive neuronal network. As the primary instrument for creating a neurosignature of pain, the neuromatrix might be genetically determined and then modified by sensory experience. Again, the impact on consciousness or on the body depends on numerous factors, and the influence on pain conduction is only part of it [Melzack, 2001].

Only in recent years has it become possible to observe the brain directly during activity—although still without much detail—for example, by means of functional magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT), or transcranial Doppler (TCD) ultrasonography [Yoshida et al., 1995; Jellinger, 2000]. Extensive studies are still missing. First results strictly point to a modulation of the activity of subcortical structures, mainly of the limbic system [Hui et al., 2000]. Obviously, the basic principle of the nervous system’s functional structure, the somatotopic organization, is utilized here [Chiu et al., 2001]. Since acupuncture seems to act by means of a mediator—most likely, the nervous system—this aspect should be discussed in more detail.

Somatotopic Organization

Somatotopic organization is the assignment of body regions and functional units to a locally connected group of neurons in the nervous system. In the case of pain, this has been described above in great detail as a neuromatrix. Both topography (Greek: topos, place) and functional anatomy are therefore essential organizing principles for the brain and spinal cord. If the body is to be projected onto the CNS, the CNS itself may give very little instruction for endogenous organization. On the other hand, this allows the CNS to learn new ways of organization and to permit new applications; in other words, the response is plastic. These endogenous organizing principles, through which the CNS can have a molding effect on the organism, include the developmental milestones of evolution that are primarily found in the live-saving control units, namely, the endocrine and autonomic portions of the brain. These are the phylogenetically older parts of the brain. It should be emphasized here that the often-heard assumption that the CNS is segmentally structured like the skeletal system is wrong. Evidence for this is found, for example, in the secondary bundling of the completely nonsegmental nerve rootlets (fila radicularia) into intersegmental spinal nerves by the somites. Likewise, the opinion that acupuncture is based on a mutual influence of internal organs and zones of hyperalgesia (Head zones) is rarely held anymore. According to this view, acupuncture would act only on the periphery through body segments or chains of myoskeletal function.

The procedures mentioned earlier—MRI, SPECT, or TCD ultrasonography—have shown that the needling of acupuncture points speeds up the blood flow in certain brain regions, leading to regionally increased oxygen supply to the brain tissue [Litscher et al., 1998, 1999a]. This is often the expression of increased neuronal activity in the affected cell population. An increase in blood flow can also be demonstrated in the more accessible arteries of the eye during needling of acupuncture points that are traditionally used to support vision (whereby the retina is understood as an extension of the brain) [Litscher et al., 1999b]. It was shown that the blood flow did not change when the test persons were needled at other points. Although these methods do not explain acupuncture’s mechanism of action, they allow one to measure the effects of the treatment objectively; they are reproducible, and they facilitate a better control of acupuncture therapy. The acupuncture-induced change in oxygen supply in the CNS can also be demonstrated after the treatment. Up to now, interest in central nervous effects has focused mainly on the release of endorphins. With the new aspect of blood flow, one can now explain far more than only pain-relieving effects. On the one hand, the altered oxygen supply in the brain may modify the conscious perception of dealing with and reacting to diseases (which might include the inhibition of pain). On the other hand, these brain areas may have an effect on the assigned body regions and body functions.

Anatomical Correlates

There are numerous reasons why the results of studies in the field of acupuncture research have been misinterpreted. First of all, the phenomena observed cannot be brought in line with the available knowledge on physiology. Second, during the 1930s, numerous acupuncture schools became established in Europe. Terms already in use can therefore be misleading. For example, what is understood as a point in the Western culture is called a hole (xue) in ancient Mandarin Chinese. Accordingly, totally different morphological correlates may be accepted, such as the point-like structure of a nerve ending, or a hole in the subcutaneous fascia of the body (superficial fascia).

The often-quoted discovery of fine structures at acupuncture points by the anatomist Hartmut Heine in 1987 provided the basis and the start of numerous studies [Heine, 1988]. Recently, his findings have been used for surgical therapy of chronic soft tissue pain. The lure of his preparative analyses is the alleged demonstration of anatomical equivalents to acupuncture points. Heine stated that acupuncture points coincide locally with neurovascular bundles. According to his findings, nerves and blood vessels run in bundles through defined openings in the superficial fascia. These bundles are 2–8 mm in diameter and of various configurations. They are kept embedded in the subcutaneous fat tissue by the superficial fascia. In fact, similar findings had been published much earlier, for example by Bossy et al. [1975] and Plummer [1980]. Neurovascular bundles have also been used to explain the alleged higher electrical conductivity at an acupuncture point compared with that of the surrounding area. However, this aspect in particular can be approached in different ways. On the one hand, the neurovascular bundle may increase the conductivity of the point compared with that of the surrounding area. On the other hand, the temperature is considerably higher in this area due to the increased blood flow [Ovechkin et al., 2001], and conductivity is decreased accordingly. However, no temperature-compensated measurements of bioimpedance at acupuncture points are available, and the corresponding point localizations should thus be viewed with caution. In any case, secondary effects (by clothing, electrode material, surrounding nerve supply, inter- and intra-individual differences in skin thickness, skin secretion, or pressure during electrode application) are not recorded by commercially available devices [C omunetti, 1995; Kwok et al., 1998; Sher, 2000]. Only the variation in electrode pressure, which is not perceived subjectively, lets the examiner find the point exactly where he/she subconsciously assumes it to be—quod erat demonstrandum (which was the thing to be proved). Generally, the special electrical conductivity of a skin area means that we are not dealing here with a morphological unit but rather with a functional one.

It is not at all unusual that blood vessels and nerves join to form bundles. During development of the body, they are forced by tissue movements to come together at relatively inactive locations. Nerves, arteries, and veins gather here naturally, even though this may in no way be caused by their developmental origin. For example, almost all large vessels and nerves run along the flexed side of a joint. Furthermore, the shift of layers against each other (subcutis against superficial fascia) can cause kinks or constrictions when vessels and nerves pass from one tissue layer to another. The location of such gathering points for vessels and nerves thus follows a pattern that does not necessarily lead to acupuncture points, and this applies also to areas where there is no fascia to penetrate, as in the face.

Thus, many more perforations with passing neurovascular bundles can be demonstrated than there are acupuncture points. It is said that 301 out of the 361 points that Chinese acupuncture regards as especially valuable for therapy coincide with such sites of passage through the superficial fascia. On the one hand, the selection of 361 points does seem arbitrary (the number is said to correspond to the number of steps to the Emperor’s palace); on the other hand, there is no reliable control. Not every acupuncture point is associated with a neurovascular bundle, but there are many more neurovascular bundles passing through the fascia than there are acupuncture points. There exists a certain correspondence between the described channels (and the points located on them) and the nerves and vessels supplying the subcutis and skin. However, the available studies—which do not mention the number of anatomically identifiable points—failed to determine in a verifiable manner to what extent, if at all, channels and neurovascular structures actually occur together. Thus, the correlation may be a purely statistical one. No causal connection can be determined from a mere correlation. Up to now, no anatomical structural correlates have been found for the channels. There are also no convincing indications of anatomical assignments for the presumed somatotopic organization underlying ear acupuncture [Peuker and Filler, 2002].

Connective Tissue

One study involved 103 patients with chronic shoulder–arm and shoulder–neck pain in which previous therapeutic measures had been unsuccessful. Particular sites where neurovascular bundles pass through the fascia were surgically exposed and dilated. The underlying idea was that the nerves and vessels found by Heine can become constricted where they pass through the fascia, and the irritated nerves then indirectly influence the rest of the body through the nervous system. The improvement with respect to pain, strength, and mobility that resulted from dilation was excellent in 41 patients, good in 29, and satisfactory in 28. There was no satisfactory improvement in five patients.

Whereas needle therapy leads to secondary scarring and therefore narrows down the passage sites, the opposite was achieved in the above study. Both acupuncture and dilation have an effect on the neurovascular bundle, but the above study resulted in a release from restraint, while acupuncture results in secondary constriction. What the two procedures have in common is the manipulation and stimulation of connective tissue [Langevin et al., 2001b]. They both cause a temporary transfer of negative charges in the connective tissue surrounding the nerves, and this also changes the excitability of nerve fibers, which depends on the surrounding charge (with collagen acting as a biosensor). Thus, instead of the neurovascular bundles or their locations, the affected connective tissue and fascia-like structures might also have an effect, perhaps by means of their innervation.

The extracellular matrix of the loose connective tissue surrounding the neurovascular bundles at classic acupuncture points consists mainly of highly polymeric sugars (proteoglycans and glycosaminoglycans) with embedded fine collagen fibers. This extracellular matrix typically also contains all types of immune defense cells. The matrix undergoes changes in numerous chronic diseases that affect the whole body. One of the theories explaining the pain occurring in peripheral neuropathies of diabetics or alcoholics, or in certain muscle or muscle–skin disorders, states that changes in the extracellular matrix irritate the neurovascular bundles.

In addition, the turning of the acupuncture needle after insertion has a measurable biomechanical effect, which can be explained by the fact that the connective tissue attaches to the needle and gets wrapped around it. Up to 170% more energy must be applied to remove such a needle. This effect is particularly prominent at the traditional acupuncture points [Langevin, 2001a].

The theory that neurovascular bundles are the morphological correlates of acupuncture points also ignores other details. The deep acupuncture points shall not be considered at the moment. But for body areas in which perforation of the superficial fascia is not at all possible, other explanations must be found to support this theory.

One such area is the facial region, which is rich in acupuncture points. Unlike the rest of the body, there is no subcutaneous fascia—it would prevent facial expressions, which are so important for human beings. Instead, the neurovascular bundles here supposedly exit from openings in the bones and enter directly into the facial skin. However, only four such sites can be found on the human face. Other nerve passages through bones are located far away from the facial skin, and the respective nerves supply organs other than the skin, i.e., they cannot be compared to the neurovascular bundles. In other regions of the skull, there are emissaries exiting from the bones. These sites rarely lie near acupuncture points and should be avoided because they are potential entry points for introducing microorganisms into the brain capsule.

Furthermore, no perforated fascial structures are found on the anterior and posterior median lines underlying the two channels called the conception vessel and the governor vessel. On the one hand, the skin in these areas receives its supply of neurovascular bundles from both body sides. On the other hand, 3-mm-thick conglomerates of terminal branches of nerves and vessels form frequently in these areas, the significance of which is unknown. Such conglomerates are also found in internal regions of the body, where they are thought to play an endocrine or paracrine role. In the region of the sternum, these formations lie within the periosteum, and—considering the common formation of a sternal foramen—one should not attempt to needle the periosteum. (Note: The term “point” would be more appropriate in this connection than the term “hole”.)

Ear Points

In the projection zones of the ear, there are receptive bodies of about 100 µm in diameter, which consist of a conglomerate of collagenous and elastic fibers infiltrated by terminal nerve fibers and blood vessels [Heine, 1993]. Their classification as typical encapsulated nerve endings (end bulbs) of the skin is still pending because their connective tissue composition differs from that of the classic structures. The very high number of these sensory organs per surface area of the ear is remarkable, and it is matched by an intense nerve supply that is strikingly dense even for the facial region [Peuker and Filler, 2002]. This phenomenon calls for a functional explanation. One may speculate that highly sensitive thermoreceptors are located here for the protection of the outer ear. It is not clear how this relates to ear acupuncture.

When considering these heterogeneous findings and their various possible explanations with respect to acupuncture points, the suspicion arises that the desire to find a single causal explanation in the form of a morphological correlate represents a logical trap. In view of the very different possible actions and the difficulty of understanding the empirical concept of classic acupuncture, it seems more plausible that there are many mechanisms of action and, hence, different morphological correlates at different acupuncture points.

Indication and Direction of Action of Acupuncture

Acupuncture cannot heal destroyed structures. However, structural damage is almost always associated with dysfunction—and acupuncture can influence the accompanying disturbed functions.

NOTE:Acupuncture has an impact on disturbed functions.

Since acupuncture influences disturbed functions, it is recommended that one speaks of the direction of action rather than of a specific indication.

Directions of action of acupuncture

• Alleviation of pain

• Regulation of muscular tone: relaxing or tonifying

• Regulation of psycho-autonomic disorders: relaxing or tonifying

• Immunomodulation

• Decongestion

• Stimulation of circulation.

Relative Contraindications

There are no absolute contraindications, but relative contraindications do exist. In these situations, acupuncture should be performed only by experienced practitioners after careful consideration of the benefit-to-risk ratio.

Relative contraindications

• Coagulation defects

• Acute psychoses

• Acute life-threatening conditions of weakness

Coagulation Defects

These include severe forms of hemophilia with an INR above 4.0. One should at least avoid deep needle acupuncture. Laser treatment is possible, or superficial needling with very fine needles (0.16—0.2 mm in diameter).

Acute Life-threatening Conditions of Weakness

Needle acupuncture regulates the distribution of qi. It is not possible to supply qi by needling alone (only by tonifying moxibustion or phytotherapy). In cases of pronounced qi deficiency, redistribution of qi can no longer occur.

Excessive Reactions, Undesired Effects, and Complications

It is possible that excessive reactions may occur during acupuncture treatment.

Excessive reactions

• Excessive relaxation and tiredness

• Excessive autonomic reactions

• Sleep disorders

• Worsening of the condition under treatment.

Excessive Relaxation and Tiredness

This may lead to circulatory disturbances. Excessive autonomic reactions lead to vertigo, sweating, and changes in skin color.

Worsening of the Condition Under Treatment

This relates mainly to a temporary increase in pain.

There are two possible explanations for excessive reactions:

• Selecting the wrong strength of stimulation (usually too much stimulation for that particular patient)

• Initial worsening in response to a stimulus (excessive reactions may occur during any regulatory therapy).

Undesired effects and complications are classified according to the frequency of their occurrence:

Undesired effects/complications

Sometimes:

Formation of a hematoma Breakdown

Rarely:

Pain and impaired sensibility in the region of needle insertion Burns Blistering of the skin

Very rarely:

Infections Organ injury

Pain and Impaired Sensibility

Pain and impaired sensibility in the region of needle insertion occur when nerves are irritated, but this is of no importance in the long term.

Burns

Burns during tonifying moxibustion are regarded as complications. However, they are a desired type of stimulation in the case of sedating moxibustion.

Blister Formation

Blistering of the skin may occur during cupping. This, too, is a temporary complication that might be desired in the case of sedating acu-puncture.

Infections

Infections occur as the result of needling in infected regions or of using nonsterile techniques.

Organ Injury

Organ damage (especially pneumothorax) can be avoided by accurate needling and knowledge of the anatomy.

Yin and Yang

The monad (Latin: monas, unit) symbolizes the indivisible unit of the two opposite poles, yin and yang.

The monad

• is probably the best known symbol in the world

• symbolizes holistic harmony through opposite poles

• includes aspects of dynamics and interaction that are essential for the existence of a healthy whole.

Yin and yang are terms for two poles that are always present in all things; they must always be understood in relation to each other.

In Chinese culture, yin and yang have never been associated with moral values, such as good and bad. What is good is not yin or yang but the dynamic equilibrium between the two; any imbalance is bad or harmful.

Yin

Yang

Night

Day

Moon

Sun

Earth

Heaven

Dark

Light

Cold

Warm

Matter

Energy

Rest

Activity

Qi

Qi is often translated as “life force” or “vital energy.” Qi is contained in everything that lives—it is directly connected with all life processes and signs of life.

Qi moves the spirit and the body, warms the body to its normal temperature, keeps the organs in place (e.g., uterus, urinary bladder) and maintains normal organ and body functions, defends against pathogenic factors, and transforms food and air, which have been taken up through normal organ functions, into special forms of qi and blood (xue).

Functions of qi

• Qi moves

• Qi warms

• Qi maintains

• Qi defends

• Qi transforms.

The Five Main Functions of Qi

Qi moves (promoting function)

• Each zang fu organ qi (qi of an organ network) performs it functions in certain directions: lung qi descends (it moves the inhaled air down into the chest); stomach qi also descends (it moves food down to the intestines)

• Lung qi moves moisture to the skin (it moisturizes)

• Qi moves blood (blood flows together with qi in the blood vessels and is moved by qi).

Qi warms (warming function)

• Defensive qi (wei qi) flows through skin and muscles and warms the body, especially the outer layer (exterior)

• Kidney qi (original qi) is the source of heat in the human body (according to traditional Chinese medicine [TCM], the kidney is the residence of fire)

• Spleen qi warms and thereby ensures sufficient transformation of food into food qi (gu qi).

Qi contains (containing function)

• Spleen qi keeps the organs in place (it prevents descent or prolapse)

• Spleen qi keeps the blood (xue) in the blood vessels (it prevents bleeding)

• Kidney qi (original qi) and bladder qi keep the urine in the bladder.

Qi defends (defending function)

• Defensive qi (wei qi) protects the body against external pathogenic factors.

Qi transforms (nourishing function)

• Spleen qi transforms pure food essence into food qi

• Kidney qi (original qi) transforms body fluids (see also “TCM Refresher,” p. 577).

Qi Production and Transformation

The total amount of qi available to the body consists of prenatal qi and postnatal qi.

The prenatal qi (also called congenital qi, pre-heaven qi, earlier heaven qi) is inherited from the parents. It is an essential part of the original qi (yuan qi) or kidney essence (jing). Kidney essence is stored in the kidney, and original qi (also called source qi, primary qi) represents dynamically activated essence (according to Maciocia). The prenatal portion of kidney essence or original qi is constantly replenished by a postnatal portion of qi: nutritive qi (yin g qi).

The prenatal qi cannot be renewed—it is slowly consumed during life. The rate of consumption can be influenced through acupuncture, qi gong exercises, healthy lifestyle, and so on.

The postnatal qi (also called acquired qi, post-heaven qi, later heaven qi) is renewed throughout life. This is achieved by three zang fu organs: the spleen, stomach, and lung. The spleen and stomach provide food qi (gu qi) from solid and liquid food. Food qi cannot be utilized directly. Under the influence of the lung, it combines with air qi (qing qi) in the thorax to form gathering qi (zong qi). Gathering qi is also called thoracic qi or essential qi; it is stored in the chest and represents the first form of postnatal qi that can be directly used by the body—it regulates the respiratory function, provides for a loud and melodious voice, and supports the heart in providing an harmonic flow of blood to the periphery of the limbs.

Further transformation and refinement of gathering qi finally lead to the formation of true qi (zhen qi). This is the final stage of refinement and transformation of qi; it circulates in the channels and assumes two different forms: nutritive qi (yin g qi; also called construction qi) and defensive qi (wei qi). These forms of postnatal qi can be utilized everywhere in the body. They support the functions of the zang fu organs and protect the body from external pathogenic factors. Original qi is required for the transformation of gathering qi into nutritive qi and defensive qi. Nutritive qi replenishes the prenatal portion of original qi or kidney essence.

The total amount of qi available to the body comprises:

• Prenatal qi: portions of original qi (which is composed of prenatal and postnatal qi)

• Postnatal qi: gathering qi, nutritive qi, and defensive qi (see also “TCM Refresher,” p. 573).

Production of qi

Name of qi

Organs of qi formation

Source of qi formation

Prenatal qi: Portions of original qi and kidney essence

Kidney

Genes

Postnatal qi:Gathering qiNutritive qiDefensive qi

Spleen, stomach, lung

Food (solid and liquid)BreathSupported by original qi

Pathology of Qi

Stagnation of qi

According to Chinese perception, qi flows in the channels and blood vessels. Pathogenic factors may cause stagnation of qi. This manifests itself as pain and tension. Stagnation of qi may occur locally in muscles (as obstructions of nerves and vessels) or as a disturbance of zang fu organs (as an internal pattern).

Rebellious qi

Each organ has a physiological direction in which qi flows. For example, the lung moves qi mainly downward. Rebellious qi moves in the opposite direction, thus producing cough as a symptom.

Qi deficiency

This may concern the whole body or individual organ functions. Qi deficiency in individual organs means that their physiological functions can no longer be met. For example, deficiency of lung qi leads to shortness of breath after mild exertion and to weakening of the defense system.

NOTE:There is no excess of qi.

Pathology of qi

• Stagnation of qi

• Rebellious qi

• Qi deficiency.

The System of Channels

We distinguish between the following channels:

• 12 regular channels: jing mai

• 8 extraordinary channels: qi jing ba mai

• 15 connecting vessels: luo mai

• 12 channel sinews: jing jin

• 12 channel divergences: jing bie.

The Twelve Regular Channels

There are six yin channels and six yang channels. The three yin channels of the hand—lung, pericardium, and heart—are located on the inside of the upper extremity. They run from the thorax to the fingertips, with the first point (point 1) always being located in the thoracic region and the last point on the fingertips (for example, point LU-11 is located on the thumb).

The three yang channels of the hand