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TheNeurophysiology of Acupuncture: a Viewpoint i Miltiades Karavis This paper waspresented at the |CMART'96 Summary Acupuncture is a specialised sensory stimulation that is analysedthrough sensoryneural pathways Therefote to understand its action we have to analyse the anatomv physiology and pharmacology of the nerious system, aided with a knowledgeot' neuroendocrinology and the chemoarchitecture of the brain. Various neural theories have been developed to explain the mechanismsof acupuncturc. lt is now evident that acupuncture reacts at local, regional (spinal cord) and Seneral (brain) levels. Thetefore, insertingone or more needles at particulat poitlts (or areas) of the body actlvates neural pathwayson three different levels, ptovoking local, re7ional, and Eeneral reactions The local reactionis a multifactorial phenomenon. The electric injury potential due to the needle, the presence and synthesis of opioid peptides at the site of injury, and substance P, histamine likesubsknces, badikinin, serctonin and prcteolitic enzymerelease around the needle, alloccur during needlinS. The reg,ional reactionconcens the activationof a larger area (2 3 dermatomes) via reflex arches.we can analyse the viscero-cutaneous, cutaneo-visceral, cutaneo-muscular and viscero-muscular reflexes and also the vegetative,stretch and polysynaptic segmental rcflexes. The general reaction mainly activates the brain cenlralmechanism of internalhomoeostasis we can explain the action ol acupuncturc ln acute and chtonic pain syndromes, in addiction and in psychiatric disease throu7h the role of central neurotransmitters and the modulatory systems that are activatecl by acupoints: opioid, non-opioid and central sympathetic inhibitory mechanisms. Kev words Acupuncture, AnalSesia, Brain, Electroacupuncture, Neuroanatomy, NeurophysiologY Pain, Spinal segmentS. lntroduction The insertion of a needle superficially to the skin, or deep into muscular or nervous tissLle or onto bone, is a sensory stimulation. Needling is normally at several points at the same time and varying the combinations of pointsprobably activates different May 1997Vol l5 Na.l World Acupuncture Congress in Copenha1en circuits; also the character of the stimulus is likely to be of primary importance for the therape!tic result By character of stimulation llable 7)is meant: i. T h e depth of stimulation (skin,rnuscles, periosteum, ganglia) li. The intensity of stimulation (de gl, electroacupuncture, laser) iil. The areaof stimulation (acupoint, dermatome, myotome) iv Thecombination of stimulation points. IHE NATUR[ OT STIMULATION D€pthofStimulaiion Skin d€rmatornes Mls.les myotomes Ligaments sclerotomes Bones sclelotomes canSlion v scera viscerctomes Pefiphera n€urolomes Ve$eis,Eands viscerotomes 0.5 1cm, s!perficial needlinS, moxa 2cm (sNT) deepneedilng (motor poi.G) deepneed ins, 2 scm, periarticu ar, He points veryd€epneedl n8 (SNT), I 6cm needling (SNT) verydeep, verystronS veryliBht stimulation, sNI = Specir/ Need/ing le.hnique lfltensity of Stimulation Lishtnimulation thin needle, no de qi M;dium nirn!lat on thln needle, lnstantaneous de ql Stron8 stimulat on th ck needle, stronS de gt, rnor€ thanone ne--dle to lhe same Point, painful st mulation Electrost mulation specia parameters (ako moxa, cupPinS, ma$a8e et .) Anatomic reSion of stimulation Motor points "jumpirg" acupuncture, musc e points (1t.4, St36) ''icg"rtor' 1- epor, {rh ef"ii"d pdr'7^nF Tender points subcutaneols nodes PaEvertebfal po nt dorsalspinal nerue, (1st branch of B adder Merdian) Zonetherapy zone5 of Head, Zarlcott, shu-mu theorv, Skinpo nts freenerve endin8s iunrnyel nated or mye inated) Ref ex points auriculaf, naso, cranio actpornts Energe(ic poinis ancient points ofTCM Acu pu nctu re i n Medi cine on 5 July 2018 by guest. Protected by copyright. http://aim.bmj.com/ Acupunct Med: first published as 10.1136/aim.15.1.33 on 1 May 1997. Downloaded from

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The Neurophysiology of Acupuncture:a Viewpoint

i

Milt iades Karavis

This paper was presented at the |CMART'96

SummaryAcupuncture is a specialised sensory stimulationthat is analysed through sensory neural pathwaysTherefote to understand its action we have toanalyse the anatomv physiology and pharmacologyof the nerious system, aided with a knowledge ot'neuroendocrinology and the chemoarchitecture ofthe b ra in . Va r ious neu ra l t heo r ies have beendeve loped to exp la in the mechan isms o facupuncturc. l t is now evident that acupuncturereacts at local, regional (spinal cord) and Seneral(brain) levels. Thetefore, insert ing one or moreneedles at particulat poitlts (or areas) of the bodyactlvates neural pathways on three different levels,ptovoking local, re7ional, and Eeneral reactions

The local reaction is a multifactorial phenomenon.The electric injury potential due to the needle, thepresence and synthesis of opioid peptides at the siteof injury, and substance P, histamine like subsknces,badikinin, serctonin and prcteolitic enzyme releasearound the needle, alloccur during needlinS.

The reg,ional reaction concens the activation of alarger area (2 3 dermatomes) via reflex arches. wecan analyse the viscero-cutaneous, cutaneo-visceral,cutaneo-muscular and viscero-muscular reflexesand also the vegetative, stretch and polysynapticsegmental rcflexes.

The general reaction mainly activates the braincenlral mechanism of internal homoeostasis wecan explain the action ol acupuncturc ln acute andch ton i c pa in synd romes , i n add ic t i on and i npsychiatr ic disease throu7h the role of centralneurotransmitters and the modulatory systems thatare activatecl by acupoints: opioid, non-opioid andcentral sympathetic inhibitory mechanisms.

Kev wordsAcupuncture, AnalSesia, Brain, Electroacupuncture,Neuroanatomy, NeurophysiologY Pain, SpinalsegmentS.

lntroductionThe insert ion of a needle superf icial ly to the skin, ordeep into muscular or nervous t issLle or onto bone,i s a senso ry s t imu la t i on . Need l i ng i s no rma l l y a tseve ra l po in t s a t t he same t ime and va ry ing thecombinations of points probably activates different

May 1997 Vol l5 Na. l

World Acupuncture Congress in Copenha1en

circuits; also the character of the stimulus is l ikely tobe of primary importance for the therape!t ic result

By character of st imulation l lable 7) is meant:i . T h e d e p t h o f s t i m u l a t i o n ( s k i n , r n u s c l e s ,

periosteum, ganglia)l i . The i n tens i t y o f s t imu la t i on (de g l ,

electroacupuncture, laser)i i l . The area of st imulation (acupoint, dermatome,

myotome)iv The combination of st imulation points.

IHE NATUR[ OT STIMULATION

D€pth ofStimulaiion

Skin d€rmatornes

Mls.les myotomesLigaments sclerotomes

Bones sclelotomes

canSlion v scera viscerctomesPefiphera n€urolomes

Ve$eis,Eands viscerotomes

0.5 1cm, s!per f ic ia l needl inS,moxa 2cm (sNT)deep needilng (motor poi.G)deep need ins, 2 scm,periarticu ar, He pointsvery d€ep needl n8 (SNT),

I 6cm needling (SNT)very deep, very stronS

very liBht stimulation,

sNI = Specir/ Need/ing le.hnique

lfl tensity of StimulationLisht nimulation thin needle, no de qiM;dium nirn!lat on thln needle, lnstantaneous de qlStron8 stimulat on th ck needle, stronS de gt, rnor€

than one ne--dle to lhe same Point,painful st mulation

Electrost mulation specia parameters (ako moxa,cupPinS, ma$a8e et .)

Anatomic reSion of stimulationMotor points "jumpirg" acupuncture, musc e points

(1t.4, St36)' ' i c g " r t o r ' 1 - e p o r , { r h e f " i i " d p d r ' 7 ^ n FTender points subcutaneols nodesPaEvertebfal po nt dorsalspinal nerue, (1st branch of

B adder Mer d ian)Zone therapy zone5 of Head, Zarlcott, shu-mu theorv,

Skin po nts free nerve endin8s iunrnyel nated ormye inated)

Ref ex points auriculaf, naso, cranio actporntsEnerge(ic poinis ancient points ofTCM

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The nervous system with i ts sensory peripheralrecep to rs , a f fe ren t senso ry pa thways , cen t ra lce reb ra l nuc le i , e f f e ren t pa thways and e f fec to rperipheral organs directs the mechanisms of actionand reac t i on o f l he body when an ex te rnaJ o rinterna stir.ulus inf luences it . The various changesin lhe external or internai environment are handledin th i s manner - I n t he case o f acupunc tu re , t hestinrulus is external (needJe) and activates mostlyhomoeos ta t i c mechan isms . S t imu la t i on rnay beeffected by simple needle pLrnclufe ldry needling),sul lcutaneous infusion of pharmaceutical substancesg iv lng mechan ica l and chemica l s t imu la t i on (we tneedling), or electf ical st irnulation (sensory blocl<),and conce rns ma in l y t he ep ide rm is , de rm is andmuscle t issue.

An in ju f y t o the sk in 1 i I ac t i va tes the senso ryreceptors of smail af lerent nerve f ibres of AD and Caxon s i ze (ne rve f i b res a re c lass i f i ed by s i ze andacco rd ing to whe the r i hey o r i g ina te i n sk in o rmuscle: large diarneter myelinated nerves Ap (skin)or type I (muscle) carly touch and proproceptronfespectively. Small diametef myelinated 46 (skin) ort ypes I l and l l l (musc le ) ca r r y pa in . - l he sma l l es tunmye l i na ted C (sk in ) and t ype lV (musc le ) a l soca r ry pa in . Types l l , l l l , lV and C a l so ca r ry nonpainful information-

Sensory distributionlhF . l i n , mL . , l - . l ; amen t . l ^ t1 r . bo re , . \ i - . t s t . r .and the vesse ls re la ted to them a fe func t i ona l l ycontrol led by defined segments of the spinal cordca l l ed neu ro tomes . Senso ry a f fe ren t f i b res f l ockt o w a r d s t h e n € u T o t o m e s , c o m i r l B l r o m t h edermatomes , myo to Tn es , v rsce ro tomes ands c l e r o t o m e s a c c o f d i n g t o t h e e m b r y o n i csomotomiu rn they come f rom. The fo rma i i on o fthese p r 'm i t i ve segmen ts o r somi tes re f l ec t s thernetalner sm.

The structure of the nervous systern is such that askin area, a muscle, a group of l igaments, a viscera,the seSment of a bone, are served by one and thesame cen t re ca l l ed a mye lo tome (Mackenz ie ' stheory, visceral-so mat ic convergence theory andper iphe ra l ne rve b ranch ing theo ry ) f 2 -51 . I n t hecourse of embryonic 1i{e, innervation of the bones,o f t he rnusc les o f t he sk in and o f t he v rsce ra r ssymmetrical. But as the organism Brows, i t loses itsinit ial symmetry. Finally, only lhe intercostal nervesp rese rve the i n i t i a l symnre t r i ca l co r respondencebetween neurotomes, dermatomes, rnyotomes andsc le ro tomes . The know ledge o f t he topograph icanatomic structure of these zones is indispensable tothe acupuncturist as i t is of part icular cl inical valuefor the localisation of diseases of the posterior oranterior roots of the spinal nerves and also for thecho ice o f acupunc tu re po in t s (o r a reas ) t o bestrmulated.

Thus, according to Mackenzie's theory, the sensorycutaneous stjmulation (e.g. placement of a needle)wil l cause functional reflex reactions to the muscles,the muscle vessels and the l igaments that receivesenso ry o r r ro to r i nne rva t i on f rom the same

A.upuncturc in Medicine

mye lo tome. The re f l ex musc le con t rac t i on , t hehypera lges ia , t he tenderness and the assoc ia teda u t o n o m i c m a n i f e s t a t i o n ( s y m p a t h e t i c a n dparasyr.pathetic hyperactivity) are locaiis€d not tothe site of the injury, but to an area at a drstance andmay involve only a small part of a derrnatome- Thepresence of cutaneous hyperalBesia associated withdeep somatic or visceral pain disorders had beenrecogn ised by many phys io log i s t s (e .9 . Head ,Sherrington, Ross, Sturge and others). We believetha t acupunc tu re ac ts a t a sp ina l o r sup rasp ina llevel, using sjrni lar neural pathways that producereferred pain (aniodromic activatlon ol receptors at adistance). Also, according to the Ieferred visceralpain mechanism and 10 the proiection-convergencetheory of Rusck, the sl( in, throu8h the posit ioning ofp a i n f u l s k i n o r m u s c l e a r e a s i n v i s c e r a l p a i n(diseases of the heart, gal l bladder, stomach elc.),wil l show us the exact skin area for st imulation toeliminate a vicious cycJe oi pain (2).

I shall mention as an example the placement of aneedle at the acLrpuncture point Stomach -16 at adepth of 3cr.. This point is in the lowef l imb, lcmoutside the front margin of the leg and 3cr. belowthe t ibial convexity (r.otor point ot the anterior t ibialmuscle). This st imulation wil l cause:

/ . Lo , d l . p r -o r ) s l imL l . u ' r o l l hc ' ' pd o l l - l . l e8thal has sensory innervation from the cutaneousbranch ofthe saphenous nerve (neurotome L3-14).

i l . Stimulation oi sensory receptors and mechanorecep to rs o f t he an te r i o r l i b i a l musc le (mo to rinnervation by the deep peroneal nerve, 14, 15,51 neurotorne).

i i i .Vasoconstrict ion or vasodilat ion (depending onthe stimulation pararneters) of the anterior t ibiala r t e r y , t h a t u n d e r t a k e s t h e c u t a n e o u s a n dT . . L d r " r l " d l i r ' : t " nn o [ l l _c " re ,

l l a Myocha las i s t ha t w i l l i n f l uence a l l g roups o lr a u s c l e s t h a t h a v e a c o m m o n n e u f o t o m a ld i s t r i b u t i o n i n t h e L 5 m y e l o t o r n e a n d i npa r t i cu la r on the l ong ex tenso r o f t he b '8 toe(Extensor hallucis longLrs) (14, 15, S1), the onBd r o s , l o r l b a l m u \ ' P . 1 . 4 , 1 , r d l \ e ; l c L .max imus musc le (15 , S1 , 52 ) and f i na l l ,

v. Activation of serotonergic and endorphinergicpain modulation systems (central action).

For al l these reasons, this poinl may be selected forstimulation in cases of back pain or sciatica with L4-S1 pa in d i s t r i bu t i on , w i th o r w i thou t neu ro log i ca lf indings.

Stux and Pomeranz a6) formulated the hypothesisthat three centres are activated by acupuncture tor e l e a s e c h e m i c a l t r a n s m i t t e r s t h a t b l o c k p a i nmessaSes.

l. The spinal cord uses enkephalin and dynorphin( I o w f r e q u e n c y ) a n d p e r h a p s C A B A ( h i g hlrequency).

/ i . The r . i db ra in uses enkepha l i n t o ac t i va te theraphe descend ing sys tem wh ich i nh ib i t s sp ina lcord pain transmission by a synergic effect of themonoarnines, serotonin and noradrenaline.

i i l - The hypothalamus-pituitary Lrses endorphin.

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Johannes Bischko fZ), analysinS the control looptheo fy ( f eedback mechan ism) s ta tes tha t eve ryacupuncture point displays ai least 4 cri teria: localaction, regional action, an action extending beyondihe region, and a general action. Watkins and Mayer( 8 , 9 ) i n a p a p e r p u b l i s h e d i n s c i e n c e ( ' 1 9 8 2 )proposed the possible activation by acupuncture(and o the r phys i ca l agen ts ) o f s i x d i f f e ren tendogenous ana lges i c sys tems : neu ra l op ia te ,hormonal opiate, neural non opiate, hormonal non-opiate, unknown opiate and unknown non-opiatesystems-

Thus we could say that by insert in8 a needle ai aparticular point, nervous pathways are activated onthree different Ievels, provoking: local reactionsinvo l v ing a sma l l a rea o l 1 -3c f i , r eg iona l( segmen ta l ) reac t rons w i th in an a rea o f 1 -3dcrndio.np(. and Bcnpral re"cl ion, SivirS d ma(si\eresponse {rom the central nervous system (CNS). Letus analyse the action of acupuncture at these threelevels: periphery, spinal cord and central nervoussystem.

Local actionThe local effect of acupLrncture occurs within asmall skin area, and is due in the main to the t issuelesion caused by pricking the needle on the skin. I tis a non specif ic action common to al l acupuncturepoints.

Deactivation of painful skin pointsThe local reaction is the result of many factors.lnit ial ly, the difference in electr ic potential exist ingbetween the needle and the layers of the skin whereit is placed, the difference in temperature betweenthe need le and the sk in , and the qua l i t y o f t heneedle, create a Salvanic current of low intensity.Tha t means tha t t he need le i s a sou rce o fmictoenet4y (10,11).

This electr ic current is capable of st imulating thecell membrane, of increasing i is permeabil i ty andfinal ly of transforming the accumulation of Na- andK+ ions in the two poles of the membrane (intra andextracellulad, Ieading the cells, the adlacent sensoryreceptors and the free nerve endin8s to a state ofexcitabi l i ty. Moreover, cel l injuries of the skin (andin part icular of the mast cel ls of the Lewis layer)provoke a secretion of bradykinin, sefotonin andproteolytic enzymes, ACTH and also of histarnine-like substances around the needle f12).

Yaksh et a/. f73) point out that three types of localsubstances part icipate in peripheral transduction ofnociceptive st imuli into nociceptive impulses (pain):i. Those that activate nociceptive afferent fibres and

produce pa in (b radyk in in , ace ty l cho l i ne andpolasslum)/

ii. Those that facil'iaie the pain evoked by chemicala n d p h y s i c a l s t i m u l i b y s e n s i t i s a t i o n o fnociceptors but are ineffective in evoking painthemselves (prostaglandins), and

i i i .Those tha t p roduce ex t ravasa t i on , such assubstance P

May 1997 Vol 15 No. l

Substance P (and perhaps other peptides) may havea ro le i n i n f l uenc ing the rn i l i eu o f t he pe r iphe ra lafferent terminals, and thus in the transduction ofnociceptive information. Like other peptides, i t issynthesised in the ceil bodies of small cel ls (type B)of spinal ganglia and the gasserian ganSlion by theribosornal synthesis of large precursor prehormonesf14 ) . As acupunc tu re i s a t ype o f noc i cep t i vestirnulation, we can hypoihesise the presence otthese substances at the site of the needle-

Therefore, the main neurotransmitter of pain at theperiphery is substance B a peptide transported bythe neural f ibres up to the last nerve terminals of thec f ibres. About 20% of the cell bodies in the spinaldorsal root Sanglia coniain substance P These cellshave sma l l somas and sma l l unmye l i na ted andfinely myelinated axons. Their peripheral processeshave been found in the epidermis and in the wal15 ofblood vessels and glands. Their central processesproject to the superf icial layers of the dorsal horn ofthe spinal cord. Also, opioid receptors are presenton primary afferent neurones (thinly myelinated andunmyelinated cutaneous nerves) and on sympatheiicpos tSang l i on i c neu rons . The re a re many f i nd inSsthat indicate the presence and synthesis of opioidpeptides in different types of inf lammatory cei ls atthe s i t e o f t i ssue i n ju ry , and because the Ioca lreaction is a kind of small inf lammatory reaction,the peripheral antinociceptive effect of exogenous orendogenous opioids wil l be enhanced, especial ly 3-4 days after the acupuncture treatment. Substance Btogether with the above mentioned substances,provokes local cl inical phenomena of inf lammationsuch as swell ing, red f lare, i tching or burning pain.

A f t e r w i t h d r a w i n g t h e n e e d l e , t h e u n e q u a ldistr ibution of electr ical potential (because of thehigh concentration of K+ions) round the edges ofthe injury creates an electr ic f lux potential f ieldwhich acts as stimulator of the free nerve endings ofthe sk in fo r 72 hou rs a f te r t he app l i ca t i on o facupuncture. The nature of the stimLrlation variesaccording to the needle, the depth of the injury thequa l i t y o f t he t i ssues and the read iness o f t henervous system of the patient.

Deactivation of painful muscle pointsThe quali ty of the stimulus depends primari ly on thedepth of entry of the needle and the quali ty of thetissue in which it is placed (target-tissue). Otten, theneedle is placed in muscular t issue to specif ic pointsthat are painful to pressure called trigger points (15),or in specif ic muscle points cal led motor points (etbporntsl.

Triggef points are painful spots in muscular t issueand are detected in many degenerative disorders ofthe spinal cord, in al l cases of musculoskeletal painof radiculopathic origin (neuropathic pain) and inlocal muscle, l igament or joint inl 'uries (especial lyoveruse syndromes). About 70' l" of al l acu-pointscoincide with tr igger points. Melzack, Sti l lwell andFox f/6) demonstrated, "A remarkably high degree(71/") of correspondence between trigger points and

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acupo in ts " . L iao has a i so repo r ted tha t manyacupo in ts co inc i c le w i th the mo to r po in l s (E rbpoints) of skeletal mux,)e (17).

The simple placement ol a needle at these poinbachieves both the inactivation of the tr iBger poinl(reduction of the lntensity and discharSe rate of pains t i m u l i f r o m t h e m u s c l e t o t h e h i B h e r s e n s o r ycentres), ancl the activatron ol spinal ref lexe!. Thereceptor or8ans of the muscular shait (propioceptivesense ) and the ce l s o f t he an te r i o r ho rns o f t hes p i n a l c o r d p a r t i c i p a t e i n t h i s p r o c e s s . T h i sm e c h a n i s m w i l l b e a n a l y s e d i n d e t a i l i n t h ediscussion about the regiona actiof of acLrpuncture.

Regional actionThere is much evidence that acupuncture acts al asp ina l segn en ta l ( reg iona l ) l eve l . Nox ious s t imu l ifrom the periphery lead to release of peptides at as p i n a l c o r d l e v e l . T h e s e p e p t i d e s ( t a c h y k i n i n ssubstance B neurokinin A, calcitonin gene-relatedp e p t i d e , s o m a t o s t a t i n e i c . ) r n o d u l a t e t h etransmission oi nociceptive information to the CNS-Us ing t rea t rnen t moda l i t i es i l ( e t f anscu taneouseleclr ical nerve stinrulation (TENS), acupunctufe andelectroacupuncture, we can block the nociceptives i S n a l s , a c t i v a t i n g d c s c e n d i n g p a i n i n h i b i t o f ysys ten rs wh ich ac t a t t he l eve l o f t he spec i f i cnryelotome- AcLrpufctLrre and electroacupuncturehave an i nh ib i t o ry e l f ec l on i n te rneL r rons o f t hes p i n a l c o r d ( l a m i n a V ) a n d l h i s i n h i b i t i o n i smed ia ted by op ia te t )a in - re i ev ing sys le r . s l / 8 ) -A l so , many abo ra to r i es have shown changes i ndorsa horn cel activity (SatinB) dLrrinB mechanical,chemical and e ectr ical si imLrlal ion of sonral ic andvisceral f ie ds. TENS to somatic areas clecreases thespon taneous and nox ious l y evoked ac t r v i t y o l ama jo r i t y o f do rsa l ho rn neu rons : w ide dynamic -range (WDR) ce ls, high threshoid (HT) ce ls, andh igh th resho ld i nh ib i t o ry (HT i ) ce l s , reduc ing theperception of pain f/9J.

This spinal action is l ikely ro be the mechanism otmany physicai r.ethods of anal€iesia wh ch are useclr o u t i n e l y i n p h y s i o t h e r a p y . A n o t h e r r e g i o n a lreaction concerns the activation oJ an area throughr e f l e x a r c h e s . T h e s e a r e p r o d u c e d a l t e r t h es t imu la t i on o f a pe r iphe ra l senso ry recep to r . Thestimulus is directed rvith alferenl neural f ibres to asensory or fnotor nuc eus of the spinal corcl and aresponse reaction is produced there. The fol owingare the various types of reflex involved:

Viscera cutaneaus reflex or splachDoJascial re exFunc i i ona l o r o rgan ic d i sease o f a v i sce ra mayinduce referred pain, hypalgesia, tension of irr i tat ionin a panicular area of the ski l l . As a genefal rule, thesk in a rea where pa in i s p ro jec ted has commone m b r y o n i c s o m o t o m i c o r i g i n w i t h t h e p a i n f u lviscera, and consequently i ts sensory inneNation isfrom the same neurotome of the spinal cord. Thes k i n a n d t h e r e a t e d v i s c e r a h a v e t h e s a r n eseBrnen ta l i nne rva l i on , Usua l l y f rom do rsa l roo ts ,sp ina l ne rves and nuc le i ( re fe r red pa in resu l t i ng

Acupun.10rc iD Me.licine

i rorn reflex pheromcna). _l_hc fociccptivc impulscs

frorn the aifected viscera pass to thc dorsal horn andthence io the anterior horn of the spinal corcl vr.1i n t e r n e L r r o n c s . V i s c e r a a i l e r e n t n o c i c e p t o r sconverge on the sanre pain projection feurons asthe afierents irom the sk.n (20-27).

An exa r .p le o l a non pa in iu l sk in response tovisceral st imLrlatiof is the actior] of barium chloridcon the descendjng colon, in blanching a skin areawilhin the T9 l2 dermalonres. Also, adrcnaline onthe gaslr ic mLrcosa, the gall bladder or thc fascia ofthe spleen, causes a shiny patch on skin supplied in' h a . . r . . a 1 e \ F . n . d . , l n . e . r 8 " - / 2 4 .

Pain irorn the gall bladder is projected to thc sl( irrof the r ighl hypochondrium and thc top of the r ightshou lde r . S tomach u l cc r pa in j s f e l t on the sk rnsL r r face w i th in l he i nne rva t i on a rea o i

_ l ' 1 l .

_ l_he

v i sce ro cL r taneous re l l ex i s l r ans rn i t t ed v ra thesympathelic chain. Thus i l is unaffecled by sectionof the spinal cord, but wil l be abolished by scctiono l t he sympa the t i c cha in . Th i s re f l ex may be o fdiagnoslic help.

Cutaneous viscera I reilexThe i r r i t a t i on o f a sk in po in i r . ay i n l l uence thefunc t i on o f an o rgan su l )p l i ed by the sa r re ne rve' u o t L p p i - * r r l l ) . r J , a r r e n t . . 1 l L o , L I F r 1 8 r opectoris, the injection ol procaine into cutaneoLrstender po in t s o f t he an te r i o r t ho fac i c wa b nSsabou t f as i re l i e f o f t he p reco rd ia l pa in . E lec t r i ca lst irnulation of the poirt Frl iu (LJ.1B) on both sides,provides analgesia suff jcient for surgical fenroVal olthe lhyroid.

_fhis poiJlt is found jn an .rfea inner!,atedby the third dorsal cervical spinai nerve. The fasciaol lhe lhyroid gland and the above y ng skin area,where the specil ic acupLrrclLrre point is found, haves e n s o r y i n n e f v a l i o n f r o n r t h e s a n r e c e r v i c a lmye lo ton re . Th i s re i l ex does r ]o l depend on thehigher brain cenlres: secl ion of the visceral nervesabolishes the ref ex and section ol the !,a8lrs fervedoes not inf lLrence the healing elfect. l t looks ikethe myotatic, monosynaptic reflexes. This reflex maybe used for therapeutic purposes.

Viscero-nLtscular and viscero-vitaeral ot sanala-attktnctmic reflexesT h e s e a r e i n t e r n a l r e f l e x e s w h i c h c a u s e t h emuscular contraction and vasoconstrict ion observedin disease of the internal organs. Sensory f ibres fromthe muscles, vessels and the affected orSan originatefrom the same myelotome on neighbouring nucleiwh ich a re func t i ona l l y i n te rconnec ted f25J . Th i sreflex produces reflex spasnr of the sl<eleta muscle( t r iSge r po in t s o i t he pec to ra l i s r . usc le ) dL r r i ngmyocardial ischaemia. Also, thfough this ref ex wecan inlerpfet mLrscLrlar paif durinB r.uscular activitywhile under condit ions of l imited blood supply (26).The sensation of needle insert ion into somatic nervee n d i n S s i n t h e m L r s c l e a s c e n d s w i t h a f f e r e n timpu lses to the an te r i o r hypo tha lamus . E i l e ren limpulses originate fron] the same reflex centre of theh y p o t h a l a m u s , d e s c e n d t o t h e c h o l i n e r g i c

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vasodilator nerve and di late the blood vessels o{ themuscle. Section of the dorsal spinal roots and that ofthe visceral nerves abolishes this reflex. A modif iedviscero-visceral reflex is activated dufing the directexcitat ion of a ganglion by placing a needle deeplyin the ganglion or al l around it . For example, thepoint S1.18, which is a meeting point on the head ofthe 3 yang meridians of the arm, may be needled inacute musculo skeletal pain. Application of localanaes the t i c t o t he mucosa ove r l y ing thesphenopalatine ganglion can block pain 127) andrnay be surprisingly effective for musculo-skeletalpain especial ly of the neck and back.

T h e a c u p u n c t u r e p o i n t S I . l B a n d t h esphenopalatine Sanglion coincide. ln this area, thereexists the largest col lection of neurons in the headoutside the brain i tself; i t is int imately connected lothe tr igeminal nerve and nucleus and the superiorcervical sympathetic ganglion, and may be regardedas the f inal switch between the body and the brain.

Somatomotor or cutaneo-muscular segmentalrcflexesA noxious stimuJus to the skin st imulates axons ofsenso ry f i b res o f g roups l l l and lV o f pe r iphe ra lnerves. The impulse enters the posteriof horn of thesp ina l co rd and i s t ransmi t ted v ia i n te rmed ia teneurons to the motor neurons of the anterior horn.T l ^ i s pd l l - \ a ) i c po l ys )1ap l r ( . pF rmr l l i r g on onehand control and on the other deviation of sensorys t imu la t i on . Thus , t he s t imu la t i on o f a g roup o fsensory receptors on the muscles, tendons or skinwil l cause contraction or relaxation of muscles inthe stimulated area (segmental distr ibution of ther e f l e x ) . I n t h i s m a n n e f , a s e n s o r y s t i m u l u s(acupuncture) may enlist neurons on the same oroppos i te s ide o f t he i n i t i a l s t imu la t i on . The usua lresponse to the sensory st imulus is the ipsi lateralst irnulation of f lexors and the inhibh,on (relaxation)o f ex tenso rs , w i th the con t fa la te ra l i nh ib i t i on o ff l exo rs and s t imu la t i on o f ex tenso rs ( f l exo r andcross-extensor rcf lex) (28,29). Most rehabil i tat iontreatments by electrophysical agents and of courseacupunc tu re , use cu taneo-muscL l l a r re f l exes toachieve muscle relaxation and to ameliorate theintramuscular blood supply to individual muscles ormuscular groups. The selection of the area to bestimulated depends on the target muscle.

Vegetative rcIlexesThese ac t v ia the vege ta t i ve ne rvous sys tem(sympathetic and pafasympathetic). There is a largenumber of short and long vegetative reflexes whichc lose the ne rvous c i r cu i t i n t he b ra in and sp ina lco rd , and i n the b ig ne rvous ganS l ia o r sma l l e rperipheral ganglia. There are not only seSmentalreflexes, many other vegetative reflexes have beendescribed in medicine. For example: the segmentaland suprasegmental reflexes that are produced dueto local biochemical changes and t issue damage inpatients with acute myocardial ischaemia (AMl).This is known as the Bezold-Jarisch reflex (abnormal

lvlay 1997 Vol l5 No.l

vagovagal reflex). l t produces severe brachycardia,peripheral vasodilat ion, severe hypotension anda t r i oven t r i cu la r b lock . These fe f l exes i nvo l veafferenis and efferents of both cardiac va8lrs andc a r d i a c s y m p a t h e t i c n e r v e s w h i c h p r o d u c esympa tho -sympa the t i c re f l exes . A l so i n AMIsup rasegmen ta l re f l ex responses resu l t l r omnociceptively induced stimulation of the medullaryand hypothalamic centres, l imbic structures andneuroendocrine systems f3o).

According to Cunn (31,32), some other commoncondit ions of autonomic dysfunction that respondwell to acupuncture treatment are the vasomotor,sudomoto r , g landu la r hype rac t i v i i y and smoo thmusc le spasm obse rved i n spondy lo t i cradiculopathy. When pain disappears, so do theautonomrc phenomena,

Vegetative reflexes can be activated by local,general and regional st imuli. Research from theUniversity of Coteborg a.l3) shows that acupuncturemay affect the sympathetic system via mechanismsai hypothalamic and brainstem levels, and that thepos t s t imu la to ry sympa the t i c i nh ib i t i on tha t i sinduced, may persist for more than 12 hours afteracupuncrure,

Vegetative reflexes are the clearest evidence ot ano rgan ism is reac t i on as an open the rmodynamicsystem. We know very l i t t le about these retlexes.The major problem is in describinS the connectionsbe tween the human co r tex and the pe r iphe ra lou t f l ow to smoo th musc les , ca rd iac musc les ,secretory Slands, sensory organs and vessels. Someorgans (heart, gut, spleen, kidney) receive bothsympathetic and parasympathetic innervation, whileother organs (adrenal medulla, vascular t issue, skinand muscles) have only a sympatheiic supply. Thevegetative nervous system, cl inical ly speaking, is notso autonomous as has been believed and seems tobe synergistic rather than antagonistic (34-36).

segmental distribution of acupointsThe main acupuncture meridians crossing the frontalt h o r a c i c a n d a b d o m i n a l w a l l a r e t h e S p l e e n ,S tomach , K idney and the Concep t ion Vesse lMeridians. During their course over the abdominaland tho rac i c wa l l , t hese mer id ians deve lop 66po in ts (110 b i l a te ra l l y ) . App ly ing acupunc tu re topoints on the thoracic area. irrespective of whichmer id ians they a re on , i n f l uences the tho rac i cviscera or their functions, and needling points onany o f t he mer id ians t ransve rs inB the abdomina lwall affects the abdominal viscera or their functions.Moreover, al l the meridians fol low a course towardsthe middle frontal and dorsal l ines, similar to ihesegmental distr ibution of deep pain that Kellgren(37) charted after injection of NaC/ in the interspinall i gamen ts o f t he ve r teb rae . The de rmo toma ldistr ibution of the sympathetic f ibres coincides withthe distr;bution of acupuncture points on the secondbranch ofthe Urinary Bladder Meridian.

The same accurate, neurotomic distr ibution ofacupuncture points on the Urinary Bladder Meridian

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occL r rs w i l h l he Covern ing Vesse l Mer id ian . l heacupLrnclLrre points lrlrg l ard 2, Urinary BladdetI l-1.5 and 4l and Coverrl /)g yesse/ /.1, have longbeen used fo r t he l rea lmen l o f l ung d i sease . A IJthese po in t s conce rn l he T2 -4 ne rve roo l s andco r respond de rma tomica l l y t o t he ou t l e t s o i t hesympathetic chain ol the dorsal lung plexus (2nd lo4lh thoracic sympathetic Banglion). The trronchaeare au tononr i ca l l y i nne rva ted by l h i s sympa the l i .plexus, as are lhe division ol the trachea and al l thevessels which transpod l) lood to the bronchial tree.F r o m t h e s a m e a n a t o n r i c n l r e S i o n s t a f l l h epreganglionic branches ol the low,er cervical ancl oit h e f i r s t a n d s e c o n d t h o r a c i c g a n g l i a o l t h es y m p a t h e t i c c h a i n , w h i c h w i l l i o r m t h e s t e l l a rganglion in the depths ol the dorsal cervical tr iangle.The shu mu technique (synchronous stirnul irt ion ofabdominal mu and thoracic, back'5hL/ points) is irspec ia l , anc ien t me thod tha t L rses the seSmen ta ldistr ibution of acupoints to treat diseases ol Internalabdominal orSans.

General aclion oI acupun( lure ,limulalion_lhe integrity of the peripheral nervous system and

spinal cord is considered necessafy for the effectiveapplication ol acupuncture, AcupLrncture points are1c f [ ' | \ . i n p : r "p ie6 i , l imb ' ' , omo le , - . c r . r , r v

motor paraplegia) and in experirnental aninrals $,i thsur8ical section of the spinal cord f l8). A peripherals t imLr lL rs , depend inE on i l s qua l i t y , n ray s t imu la lespecii ic nuciei of lh-. CNS and provoke secrel ion orq u a l i t a t i v e m o d i i i . a l i o n o l r e u r o l r a n s m i t l e rsubstances in lhe blood ar]d CSF- Besides this, eachcon b ina t i on o l acupunc lu re po in l s may ac l i va ledifferent nerve circuits. This view is based on experi 'mental results from the University of Peking f39).

Experiments on rabbits have shown that fol lowingarterial anatomosis of two rabbits (cross circLrlat ion),ana lges ia i s ach ieved no t on l y f o f t he fabb i t on\ , vh i ch acupunc tu re i s app l i ed bu t a l so fo f t hes e c o n d r a b b i t i n w h i c h t h e b l o o d o f t h e f i r s tc i r cu la t cd th fough thc anas tomos is . Fu r the rmore ,CSF t rans fus ion f rom a ca t r , vh i ch had rece i vedacupunc tu re ana lges ia , t o ano the f ca t j nducesanalgesia in this second cat after l0 minutes. Sincet h e s e e a r l y C h i n e s e e x p e r i m e n t s , t h e r c i e a s efol lowing acupuncture oi analgesic neurotransrnittersubs la r - r ces to the CSF and pe r iphe ra l b lood hasbeen repeaLed ly coDf i rmed , demons l ra t i ng l heac t i va t i on o l cen t ra l pa in con t roJ sys lems (ando the rs ) t h rouBh acL rpo in l s . The naming o i l hesep o i n t s i s a c c o r d i n g o n o f e h a n d l o l h e i rt opoSraph ica l pos i t i on and o r ] t he o ihe r t o i he i rmain therapeutic action. Their specif icity has Lreeni n v e s t i g a t e d e x p e r i m e n t a l l y o n a n i m a l s a n dc l i n i ca l l y on pa t i en ts , and i t has been found tha tr a n d o n r l y s e l e c t e d , s h a m a c L r p o i n t s h a v e a nanalgesic effect on 28 35% of patients, compared tokadit ionaJ acupoints that have an analgesic effect in55 85 '% o f t he pa t j cn ts . Papers pub l i shed haveinvolved the acupoints: lung 7, Stontach 36, Lar1eintestine 1 and 10, Splcen 6, Triple Enert iser 5,

AcupunctLrc ln Mcdicina

l i ,er , and Pericanliun) 6. The syslenrs ircl ivatedlh rou€ ih thes€ po in i s may l l e e fdo8er ro l r s op io idanalgesic systcms, fon opioid systerrs, ar)cl cenlralsympathetic pair inhibit iof syslems acl i fg IhrolrghIhe re t i cu la r I o rma l i on o i t he b ra in .

I n r e c e n t y e r r s , i h e a n a l S e 5 i c a c t i o n o iacupLrnctLrre has beer used mainly iof lhe lrealmenlof acute and chfonic pain, and to a small erlent iors r r g i c a l a n a l g e s i a w h j c h i s e i l e c t i v en e u r o c h e m i c a l l y t h r o u g h t h e d e s c e n d i n g p a i nconlrol syslenr. I his consists ol loLir parls: lhe spinalsysler. (dorsal ho ), lhe codical and diencephalicsyslenr, the mesencephalic (PAC and PVC) system,and l he pon l i ne (nL l c eus raphe n ragnus ) sys tem.F . l ch sysLem Uses d i f f e ren t endogenous op lo ldpep l i des l , J0 , , l t ) . The re i s c lea r ev idence o i l heanir lBesic action oi acLrpun(ture in this f ield: of 1500aclrpuncture art i( les on the Me.// ire dntabdse, 1100concern ana lBes in . lmpor tan l i n l he l i t e ra tu re a reabora lo ry s lud ies on expe r i r l l e l l t a l an i r . a l s a fd

( l i n i ca l repo r t s f rom ve te r i nn ry c l i n i r : s , . r s . rn ima l. ,U l o . . ' r e l e . . I r l * l ) t o L re \ . rL r c , t , , - . r sba . t rnhypnosis, or placebo eifect.

Pomeranz 16) detai ls experimental suplrort for theendorph ine rg i c ana lges i c e f fec ts o f acupunc tu re .T h e a n a g e s i c a c t i o n o f a c u p u f c t L r f e c a n b e' . d I i " d i n . . n r m b . r u \ ^ . \ ' . l h . o p . r l nafLrgonist, ,a/oxoDe, abolishes the analgesic eflecl,either sysLemical y or as a microinfusion lo the CNS.Also, iniLrsion ol endorphin antibodies into lhe CNSc a r r a b o l i s h L h e a n a l B e s i c e i l e c t . M i c e w i l l l ag e r ] e l i . a l l y r e d u c e d c o n c e n l r a l i o n o l o p i a l erecep lo rs i n t he CNS have a poo r re \pon \e toa c L r p L r n c t L r r e , a s c l o r a b b i t s w i t h e n d o f p h i ndeiic ency. Endorphin levels increase considerablyin periphera blood ancl in the cerebrospinal f luidduring electroacupuncture, while at the same timelevels in the CNS are reduced. The irnal8esic effecto f a c u p u n c t u r e l a s t s l o n g e r w h e n e n z y n r a t i cdegradation of endorphin is inhibited. The analgesicagen t o f acupunc tu re i s t ransmi t ted th rough theblood (cross circulation) and the ccrebrospinal f uid.I h e e l i m i n a i i o n o f p i t u i t a f y e n d o r p h i n b yhypophysectomy abolishes the acupuncture effcct.A n i n c r e a s e o f t h e n r e s s e n g e r R N A i o r p r oen <ephalin jn the bfain (pjtuitaryJ is observed ior 24'18 hours fol lowing acupuncturc.

Abou l 60% o f p . r t i en ts su i fe r i ng i ron r ch ro r r i cnryofascial pain relatcd to the lumbar port ion of lhesp ina l co rd a re cons ide rab l y re l i eved a l t e r t heapp l i ca t i on o f warn r con rp resses (a t 43 -51"C) o rultrasound, and the improver.enl oi symptoms lastsfrom 90 minLrtes to 7 days; Price et a/- iound thatapplication of electroaclrpLrncture to local acupointsrel ieved 587. of the patients for weeks or months,up to 3 years f, l2). Han sug8ests that the specif ic,lon8-term anal8esic effect of acupuncture is due totwo factors f, l- lJ. The activation of a serotoner8ic andmet enkepha l i ne rg i c neu ro log i ca l c i r cu i t i n t heupper part of ihe descending pain inhlbitory system( i n t h e m i d d i e n e c e p h a l o n ) ; t h i s r e s u l t s i r t h ccon t i nuous i nh ib i t i on o f noc i cep t i ve s t imu l i a t a

38 ^.1at 1997 \/al 15 No.1

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s p i n a l J c v c l , a n d t h u s n o n p e r c e p t i o l l o f p a i ncen t ra l l y . A11d the pe r iphe ra l ac t i va l i on o i l owlhrcshold muscular nrechano rcccpiors, incrcasingthe activity of largc diameter ncrvc f ibres (the painm o d u l a t i n g s y s t e m ) a n d g j v i n g l o r ] B l a s t i n ginhibi l ion of nlLrscular pain. The long{erm analBesiceffect of acLrpufctLrre is the rnost di i f icult area top rov ide an adcqua te sc i cn t i f i c hypo thes i s . Han ' s' " ' o r y o l l u u - r . o \ , B h ' n n r o l m b i , " r : l g ' rs y s t e m n r a y c x p l a i n o l l e o i t h e a c u p u n c l u r canaigcsic mechanisms a,l4l- Activation oi "Dit ' iuse

Noxious lnhihi lor), Colr lrols" (DNIC) tr iggered bynoc i cep l i ve pe r iphe ra l s t imu l i ac t i va l i r g A5 and Cfibrcs can be al lolher mechanism lor a ceftral actionol acuput' lcture, and involves compler Joops fromsp ina l and sup rasp ina l s t ruc iu res 1 , r5 ,17 ) . f h j ssugges ls tha l neL r ro t ransn ] i t t i ng subs tances o f t hespinal cord and CNS, both opioid and non-opioid,a re l l r e ma i r co -o rd ina to rs a l a " s t i n ru la l i an -analysis response" phenomenof and thal they areresponsible lor the general ised internal reaction ofthe organism thal fol lows an acLrpuncture treatment.

ElectroacupunctureElectroacupunctlrre ana gesia is a well establishedphenoinenon 148-501. In Seneral, a lower (1-15Flz)pu l se repe t i t i on ra te o i e lec t r i ca s t i n lu la t i on r s" . . o , r_ .d $ th . l u16 - . im_ u rp r , l - n " r im . - rnanal8esia, and a longer lasting effect. A high p!lsefate (100 200H2) rapidly induces a maximum painthreshold, but the effects last for a shofter periodi T a b l e s 2 a n d - : l ) . A l s o , s t i m u l a t i n g t h ep e r i a q u e d u c t a l c e n t r a l g f a y ( P A C ) p r o d u c e sana gesia similar to acupuncture anal€lesia in manyrcspccrs.According to other studies by Han Ji-Sheng and Xie

C u o X i ( l 9 8 5 ) h i g h i r e q u e n c y s t i m u l a t i o n o facupuncture points has a mainly local action, whileI n u i p q u e r , 1 l ^ a a g " n e 1 3 ' . o d d r d B A ' d ' r ̂ r' q / . \ r l F p r r a l , o r d . " ' f i . r . d l i r e q L r e n , r p d r Finefiecl ive.

E ectroacupunctlfe at a frequency oi 2l lz providesana lges ia .na in l y t h rough re lease o f me th on rneenkepha l i n , 100H2 ac ts ma in y th rou8h re lease o fd y n o r p h i n A , w h i l e w i t h 1 5 H z b o t hneurotransmitt inB substances are detected In almostequal quantit ies. Recent unpublished work suSgeststhat st imulation at a frequency if excess of 1oHzlnc reases enzymat i c deg rada t i on o f c i r cu la t i ngo p i o d . l 5 L - . d J , 1 8 r h p . r n . 8 F . i ' F h F , .

Also , new e lec t ro the rapy techn iques such as"M i c racu r ten t E lec t t i ca I Neuramuscu la rSiimu/at/on" (MENS), and elcctroacupuncture withcurrent intensit ies in the order of 400pA at 10-60Volts ( low voltage pulsed microamp stimulation) andan ex l reme ly l ong pu l se du ra t i on w i th the to ta lcurrent equal to 5x10' coLrlombs/sec, are await ingthe resuLts ol cj inica tesE f5253). This technique isba .cd o r \ c q r r L l t -S , hu l z l . r \ ' \ u n i , r odmpara( p A ) c u r r e n t s a r e b e t t e r a t e n h a n c i n g c e l l u l a rphysiology than are cu[ents of highef amplitude.S e v e r a l c l i n i c a l s t u d i e s h a v e d o c u m e n t e d t h e

Nl. i r 1997 vol15 No. l

enhancing elfects of MENS on wound healing, ontendon repair in animal models, and on the recoveryof inj lrred athletes suffering from ruptured l igarnentsand tendons . A l so , l abo ra to ry s tud ies show theab i l i t y o f t he MENS dev i ce to s t imu la te ce l l u la rphysiology and growth: increased ATP by almost500%, increased membrane transport by 30,10%afd increased pfotein synthesis by up to 73%.

Thc endogenous op io id pep t i des , endorph ins ;c n k e p h a l i n s a n d d y n o r p h i n s , a r e n o t a c t i v eexc lus i ve l y i n t he l i e l d o l pa in . They have c l r rec tei iect in al l forrrs of dependence: drugs, smokinga n d a l c o h o i s m . L o w l e v e l s o f m e t h i o n i n eenkephalin have been found in patients sufferingf r o m P a r k i r s o n i s d i s e a s e , a n d v e r y h i g hconccn t ra t i on l eve l s have been repo r ted ' n t hedorsal coch ear nucleus and intermediate genicuiatebody in patienls suffering lrom schizophrenia. Therei s a l s o s i g n i f i c a f t e v i d e n c e f o r a r o l e i n t h eregulation of food inlakc f54J. In part icular wjthregard 1o obesity, j t has been found that there is ala r51e number a f " sa t i a t i an " pep t r c les and" st i t1tu | at i n I .rppeli le" peptides in the hypothalamicnuclei of the brain and in the gastro-intestinal tract,f u n c t i o n i n g a s h o r r n o n e i n h i b i t o r s o r

LOW fRTQUENCY (HICH INTENSITY)ELECTROACUPUNCTURE (4HZ)

AcLivation ol efdotti ne€ic sy5lenrSlos, onseL oI .nr l8es a-ong hn nB r fa Besic e i iec lCeneralised afa Besic eilecl kl Ii!se ana gesia)

N./orore reversib e analgesiaPeEisc lonS after term in ation oi the nim!lus5t im! lates the sensory receptors ofd€ep musc es causing

thc midbrain PAC to release enkepha ins, activates theraphe nuc eus and rct c ! ar mignoce lu lar n lc e!s , indact vates the PAC endorphin synem

Afalgesia main v d lc to mcth ionin. cnk€phal in .

HICH FREQUENCY (LOW INTENSITY)ELTCTROACUPUNCTURE (2OOHZ)

Activation of monoamines (serotonin, norddrenaline erc.lRapid ly developinS ana gesiaShorl lasting analges c effectSegmental y disft blted ana Sesia (locn ised)No c!m!lative effectNol ,a/orone reveE bleNo pe6is l€nce af ler tenninat ion o i the st imulrsNo m!s.le tw tch lt€tanic contraciures)A , t \ . t 6 \ . 6 . . r ' p h p . " n d d i r . , t ) r - ' , . ' l r

dorsola lera i !n i .u l !s serotonin noradrenal ne descendinSinhib i tory sys l€ms lbypas n8 th€ PAC cndorphin synem)

a - . , . 1 . " , , r , l \ ' . o r i n \ " n d D r . r ; l \

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neu rotran s m itters f55). l t has also been cl inical lyestablished that acupuncture acts on the systernsoulJined in Table I (56).'fhe actton on these systenrsmust be attr ibuted to the abil i ty of acupuncture toinfluence CNS fur] ct ion.

The Nobel winning neuroscientisl Cerald Edelman

l57 l rnen t i ons tha t t he re i s no more comp lexfunctional structure in the universe than the humanb r a i n , w h i c h i s a n e t w o r k c o m m u n i c a t i n ge lec t rochemica l l y w i th bo th the ou te r and i nne re n v i r o n m e n l . l t e m i t s a n d r e c e i v e s d y n a m i cro m" o ,1 . n i . i g ra ' . a r d d r ' . se l o 11 . . " . g r , 1 . .I t s neL r rons i n l l uence the Iunc t j on o f t he hea r t ,k i dneys , l ungs , musc les , t he sk in and g lands . Theb r a i n r e S u l a t e s b r e a t h i n g , d i g e s t i o n a n d b l o o dcirculation; and analyses the acupuncture st imulus.Thus, throuBh its neuroloSical action, acupuncturecontributes to the balance of the chemistry of ournervous system and can inf luence the hundreds ofneurotransmitt ing substances that regulate in wholeo r i n p a r t o u r h e a l t h a n d d i s e a s e , e m o t i o n a lbehav iou r , i ns t i nc t s , des i res and psycho log i ca ld'sposit ion. Depression is related to disorder in them e t a b o J i s r n o f n o r a d r e n a l i n a n d s e f o t o n i n ;amphetamines have an antidepressant effect; andbenzodiazepine receptors are to be founcl In thec e r e b e l l u m a n d l i m b i c s y s t e m . C a m m aa m i n o b u t y r i c a c i d ( C A B A ) i s a n i n h i b i t o r yneuro i ransmi l l e r ( t h rough the K+ , Na+ and C /_pumps) and has intense anxiolyt ic acLion f58-67)-

Acupunc lu re i s L rsed fo r t he t rea in ren t o l am u l t i t u d e o f d i s o r d e r s s u c h a s m e t a b o l i c a n dendocrine disease, mental, respiratory and digestivedisorders, al lert ies, neurovegetative disorders etc.Reference to the neuroloBical theory of acupuncturefor these disorders is based on the one hand on ahomeostatic role for the feticular forrnation of theb r a i n , a n d o n t h e o t h e r , t h e m u l t i t u d e o fneu ro t ransmi t t i ng subs tances tha t a re de tec tedperipheral ly fol lowing treatment with acupuncture:c h o l e c y s t o k i n i n , b o m b e s i n , n e u r o t € n s i n , C R H( c o r t i c o t r o p i n r e l e a s i n I f a c t o r ) , d y n o r p h i n ,

A.upunctL!rc tn Me.licine

neuropep t ide Y , enkepha l i ns , am ines e tc . and i nthe i r mode o f ac t i on , sec rc t i on , ac t i va t i o r ] ande n z y m a t i c i n a c t i v a t i o n . l t a p p e a r s t h a l t h e s es u b s t a n c e s a r e s i r n i l a r i n a c t i o i r t o c l a s s c a le n d o c r i n c h o r m o n e s , a c t i v a t i n g n e g a t i v e a n dp o s i t i v e f e e d b a c k m e c h a n i s m s . T h e r o l e o ia c u p u n c t u r e i n t h e s e d i s e a s e s h a s b e e n o n l ypa r l i a l l y c l i n i ca l l y es iab l i shcd , and the moc le o iaction is purely conjectural.

Reticular formationlhF rp t , u ld fo rnd t i o , n t r . t . t . n f B rn tp - n t rpL | , r .and r - reu ra l f i b res wh ich un i te the ce reb ra l nuc le ia f d e a c h s e p a r a i e l y w i t h s u b c o r l i c a l c e n t f e s :t h a l a m u s , c e r e b c l l u r n , p a r e n c e p h a l i c c e n t r e s ,medulla oblongata and spinal cord. Functionally, i tcontrols the mechanisms of wakefLrlness, sleep ardlevel of consciousness, and those ol rnLrscular tone,cardiac and respiratory rhythm, and blood vesselto r ]e , reBu la t i ng and med ia t i ng mo lo f , au tonomicano sensory runclrons_

The re t i cu la r f o rma t ion rece i ves i n fo rma t ioncor]cerninB the senses, analyses it quali tal ively andquan t i t a t i ve l y and , t h roc rgh mu t i p le synapses ,transforrns i t to a slow rhythm. As a result of thisanalysis, \ ,hen the nervous signal cominS from theperiphery reaches the upper centres (bfain nuclei) i ti s d i f f e ren t i a ted f rom the i n i t i a l impu lse . Th i sa c c o r d s w j t h t h e h y p o t h e s i s t h a t m e c h a n r c a ,t h e r r n a l a n d c h e m i c a l n o x i o u s s t i m u l i a f f e c tn e u f o n a l a c t i v i t y i n t h e m e d u l l a r y a n dm e s e n c e p h a l i c r € t i c u l a r f o r m a t i o n , e s p e c i a l l yaround the nucleus gigantocelu ar s. Also Melzackand Casey f62) suggest that reticular neurons rnaymediate Ihe affecl ive/..ot ivational dimension of thep a i n e x p e r i e n c e a n d p a i n - r e l a l e d b e h a v i o u r ,r rd r , a r s ; o le i o lhp e r , u l r ' f n r rd t i . 1 ' pd r rperception and modLrlal ion.

This descendinB modulatory system may produces u b s t a n t i a l f u n c t i o n a l a l t e r a t i o n s i n p e r i p h e r a lor8ans. Indeed, irnplantation of electrodes in certaina reas o f t he re t i cu la r f o r rna t i on o f t he rnedu l l ioblongata, part jculafly those oLrtside the cerebral' r r , , l - , ; u .eo , h . rnu - ' o r . r ' e l r l a r . . r . . uc . ' _ r ; . ,a n d f u n c t i o n a l l e v e l i n g u i n e a p i 8 s , s L r c h a shydronephrosis, organic dysplasia, bone deforrnitye tc . l t see rns tha t t he ac t i va t i ng sys tem o t t hefeticular forrnation regulates the level of response otthe functjonal nuclei of the CNS, dependlfg on theinformation it receives from the sellsory pathways. l tcan enhance or repress a mult i tude of visceral andpsychological symptoms such as anxiety, respiratoryphenomena, sweating, insomJl ia, jrr i tabi l i ty, cardiaca n d r e s p i r a t o r y r h y t h m , a n d v a s c L r l a r l o n e .Interference with the homoeostatic mechanisnrs oft h e r e t i c u l a r f o r n r a t i o n c a n b e a c h i e v e d o n i yr l _ oLBh .Fn -o r ) . i TL ld i . n d ' Jp r r ' r ro . \ e r )possibly a suitable such stimulus. Part icular pointssuch as the auricular points Shenn'etl , Jerame andMaster sensorial point, and somatic points such asHT.3 and 7 , 11 .3 , C8 .20 , 5T . ,+1 , PC.6 and 81 .10have an eqLri l ibrating effect on mental diseases and

THE SYSTEMIC, NON-ANALCESIC ACTIONOF ACUPUNCTURE

CardiovasculJr systenr

lperiphedl and L)tain cnculaLiah)

la.tian on natat netve candu.tion velacitf and sensarynerve candu.lbn vehr ity)

Red and whi te b ood ce s and ce ld i i lerent ia lco lnttchanles in bload chcnistry)

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arc Lrsed on patierts w th ntense y somat sed mentadr9.]rders.

Conclusionl ' he res to ra t i on o f n ro rpho log ca l and l unc t onahomocos tas i s . l f d t hc rna in t c fancc o l a c l vnamiccquil ibrium in thc bod,v, lhat is gfadua ly festored.rf ier acul)unctLrre tfeatnreft, ma-v be exp a ned if u,ec o n s i d e r t h e b o d v a s a n o p e n t h e r m o d v n a n r i cs ! s ie f r t ha t can co a te ex te rna i n fo rma t io f anc lmod i i , v t he i unc t i on o l i t s sys tems acco rd ing l v .A c u p u n c t u r c i s m c c h a n i s m o l a c t i o n . r n d t h el rad i t i ona l co fccp t o i v i t a l cnc rg ,v c i f cu la t on a reoften dir i icLrlt iof doctors to accept. Nonethe ess,i f ad i t i on . r l app l ca t i o f s o i t h i s t he fapeu t i c sys tem,derived from soufces ost in the depths of t ime butcJ n i ca l y vc r i f i cd i n cvc ryday mcd ica l p rac t i ce ,should bc a start int point for cor] lcnrporary nrcdicalrcscarch. Notc lvc l , that thc phys cjan s not obl gedto s tudy Ch incsc ph osophy i n o rde f t o p rac t i se. lCUpUnClUrC.

I should point out that the unfeasoned fejection ofa n rc thod s | l o t a sc ien t i j c pos i l i on . l f t hch l s to ryo isr_ience, l lre molive force ol progress has l leef thci f n a l e t e r ) a l e r i a y t o w , a r d s i n l e r p r e l a t i o r r a n difvcstigation oi natura phenonrena. No mattcr howr r a n y p r o h l e m s w e i a c e i r l h e p r e p a r a t i o n o fr e s e a r c h p r o t o c o l s t o e s t r b l i s h t h e a c l i o r r ,i nd i c . r t i ons , con t fa ind i c i r t i ons and s i c le e f i ec l5 o lacul)uncture, their solution must remnin a tarS-.t of

"Fa( h ad(l i t iot l of knon'lecle,-- is at1 addit iot l t : ' lhunan po\/er." H()t al io,

Miltiades Y KaravisD i rector, Hel I en i c Ac upuncture Reser/ch Centrc

2, Alkmanos SbeetI 1528 Athens, Creece

I 51!xC, 'o. rer .drB1l9() ) 8r r l . r o / A. !p!n. /oe. 5p r in8e.Vef l .B, B- . r l n : .1 l9

2. Boni .a L Pro.ac. P1l9. r0r CcncLr l consldcrat ons o i ac! t .pa n n: Eon .a l , c t l Ttu Mana\cnent o i Pr , r . Lea &F e l i s e r , P h . d e l p h . : r 5 ! 7 8

' I |n ,+ i Ta 1r96t i r f 'a ihophysb ory , ) i pr i . . ln S,r !nders \ 'VB,er) tr1.dn.l t'ltbiolorr .txl Bi.)pltbi.t. tath edltb.: )ai

.1 lorev JA r r9r7r Vis . -pfa l pai . . Bt i t ish Mednel loun)a| . 2 :1270

5 S n c a i r D C , [ t d d . l C . F c d c W l l l ] 9 . 1 8 1 R . i . r r c d p a i ia fd issociatcd phenonr.na. Btah ,1:181

6 5t ! \ C, Pomcr.u l l (1991 ) l i .^ t .s o lA. ,p, r . lu- - Spr in8eFVer l rB, Ben r :6 ' /

i B i5ch[ , ] l1r !86r ht tetnEt l i , tLe Acut)un. turc. HarB Ver lag,

8 L e e M H M , L i a o l S 1 1 9 9 0 ) A c l p u n . l ! f e l i p s y . h a t l v . l i lKollke lF. Lehmain Fl, eds. Krdser! Hrrdbodk at Phvsl.ajI r . . r i . i D . i r . / R c h a b i l i t a t i a n . ! V B S a u n d c r s C o . ,Ph adc phiar .+0: 27

9. \ 'Vatk i is LR, N1ay.r DJ i1982) Organizat ion o i encroq,- io lsop nte and non op a ie pr i f coni r . r l s \ 'ncm! Scren( . - . 216:] ] 8 5 9 2

l r : r B e . h e r l t , 5 e d e n C ( 9 8 5 ) T h e b o d r e l e c t t i ct le . t tanbB"et i {n .nd Lhe l . ,nr l . tbn , / / , re \ / Motu. iN,

t\1ar tL)t)7 Vai I5 I'ia.t 41

T r8ovisre | (lll9l) reotia .i pt,).t.a .cupdh.tutii naderne.A. id-"nr i - " Rofr ine, B! . ! reni : 20l ,18

l l R o s c n t h a S R , 5 o n f . n s c h c I R R ( 1 9 4 8 1 H r n a m r f e a s aposs b l . chcm ca nedi i to i t . , r c l taneols pain. A,rer i .anl . i rndla i Phrsblorr . t55: 186' rA

I I L lo i . i l , Y l ah I I eLresk nd lC, Pe.hn ck RN, Lrepiht is A(r990) l l iochenis l r r , rn,J rnod! a l ion o i noci (epi ion indpr i i n : Bo. . i l , ed f te MaraA€/rer l o t Pai r . Lea &l :cb 8cr , Ph .d. lphia: 96 l -10

1.1 lo i t ! er U5, Cadd! n JH ( l9 l r I , \n ! f idef l l ied lepressivesubsiance in .cr t r in t issue erLrrcLi hu.nal at Phytb logr

r 5 r r , v e I l a i . S n r o n s D C l l 9 . r 2 r M y o f a s c i a i p a i n e n ddrs iDn. t lan. V. lu lne. t and 2. Wi l l am, and W lk l fs ,BJl l ore, USA

la Mczack R. St i lwcl l DM, [o\ tJ ( ]977) Tr Bser ponts rndac!pun. ture points tor pr l f : .o tebl ion af t l inrp i .a l ons.t 'a tn 3: a-21

l i I r o S l l l 9 i J l A . ! p ! n c l u r e p o n t s a n d t r E g c r p o i n t s .t ' t . r r ?e.1 i na; . i t \ n)e. i . . n . .n gtess ot rc habi I l ta t ian,redn:r/rp. t.sl-"rn se.f on ain!a mccting. Washln8ton

I t i Cheig RSS (1989) Nc!rophysio logy of e lect ro ic !p!nct ! reanals.s.. li: Pomcranz U, Stu\ C, els -s.l..nriin: brses of, . !p ! r .&/e. 5pr rge.Ver iaE, Ber i . r 119 l i

l ! Lnr isor U/ ) , Forenrai DR (1994) Decreased a. t i ! ty otspo.1. .eous an. l for o ls f cvokcd doEa horn cel ls d l r ngLfrns.u lan-pous -p e. t r .a ncrvc st m! lat lon (TtN5l . Pr i r .

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n r e c h J n l s r n s o i c ! l . i f e o ! s h y p e r a l g e s i a . l i : F e l d s H L ,l r l n . , l . , , " l \ / . , t " t P e p " t , ] , dIheL'p\., vohnrp 9 ltave. l'fe$, New York:51 71

2: . Kel ls ef l ts ( l r l ! r ) O. lh-" d is l f ib ! l on of pa n ar s inS t romleep \om.t ic sLru. lL fes w th .har ts of segm.nta l pa n areas.C I i n i'al S. i -"n.-. I : ) 5

2l Ke lBref lH (19i7) Obs.r ! . t lons on retened pr n . r ls ngrronr nr lsc . . C/nr i .a / s . icr .e. J i I76

: : . 1 l a n i I ' ( 1 9 7 7 ) 5 . i e r 1 i l t . i i p e . r s . t t A c u p u n . t u r eH e i n e n r r n n , l o f d o n r l 0 - l 8

_ , L r . , t b . v 6 . 1 . . t , n ' ! . d r , . dbJsed of in id, j l e \ ] )er inrefb In, Pomeranz B, St lx C, cds.S. ient i i i r l l . tes d A.upunctute. Spr ingeFver ag, Bcr n

26. Le BaE D, W I cr lC, d. Brorcker T, Vi lanelva L ( 989)N. ! rophys o loE.a l mcchan snrs involved in the pai . -rc l ic ! nE . f i .c ts of counter in i ta t ion rnd re nted techniq lesi n c u d i n s i L ! L r ! r c t ! r e I n : r ' o m e r a n T B , S t ! x C , e d s5.i.-nliiir utse5 ol Adtlnn'.i,.e. Springer Ver ag Berlinr 790i

27 l t !5se A, Sc!ddr AR 11.r9.1) Spheio palat nc gang onb . . k , t h . i i n a l S a t e t o e w i t c h i n E a i l p a i . l l o u . n a l o iMut.ulaskclctal Pain. 2: 117 41

1 8 r \ . 1 ! r r . v r \ 1 ( 1 9 9 5 ) S L r i n J C o r d I n , C o i i P M , - " d .Ncuroi . ten.e in t t led i . ine. J ts l ipp icol l Co. , Ph ladelphla lt 9 ; : 0 9

29. r.,\min CS, l)e airoot I 11995r aotplatlve NeutuaDatanv. pp el('i & La.ge, USA

l o . H r m m e r m e i s l e r K E ( 1 . r 9 0 ) C a d i a c a n d a o r t i c p a I I n :Boi.a l, ed. Ihc /ViraS.ncnt af Pain, 2nd edltion. Lea &F.biEcr , Ph idc lphia.2: 1001 l6

l l Cuin CC (1996) Tre i t ins myolJsc i i l p . n. . .dpth. tDrc inMc. l ic tne 11(1) :241

l2 Cunn CC l l989l Neuop. i th ic p i i n : a .ew Lheory lor chfon cpr in o i n i l ins c or ig in Acupuncturc in Me( l i . i .e .612) :5A- l

: l . l . A . d e r s o f S L ( 1 9 9 5 1 A . o p ! n . t ! r e f r o m e m p l r i . i s m t os. - "n. - " : Fon. l lonal backSro!nd to acup!nctur . c f iccts lnpaif efd .l t€at€. M.di.:/ / lypathctcs. 15tl):271 81

l . l . Pru ia S, Batenar! O, Chcta O, Mota M, Kara! s M, Col .eaD {r.l86l Nc!rcv.rgct tl€,esltrre rcuded by rcactomettras indi .atat a i ta .ept t rnf lo a.up!n. ture Disser tat ion,Univcts ty or Blcharest

l5 Kara! s l !1 (1985i Ee/r l torships beLu,een e lecL. ica l sk ihpatL'ntt.ls, peTeptur thrcsl)ald h an ele.ni..tidulDs ahd

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tht: ribrated set*iL.rltr Lo p.tients \rl!h., rrith.\n.1iab.ti.,eu/oprr

) isseni l od. ! l i leAi ly o l Bur .harcn16 Brsnrijrrf v) t19n9l Biateedba.k, Jd .dltior. W ll rnr &

wi lk inr , USA: l7 2717. Kel lu fen l l l 1 l9 l9 l On d inr ibut on o i pJ i f . r i5 i fs i r .n . l - . - "p

somat jc s | ! . tur fs w th crr r ts o i sesdrenla l p. i . a /nrr . r /S . l c r . c . 1 : 3 3 1 5

lLr . Nlacdonr d A i1989) A( !p! i ,c t ! re r f r lger ia. l fan( l taneo!sner le s t r ! nLb r (TN5l ;n . l !as. ! lar enects. l i r \ !a I PD,Mer! .k l t , e . ls t i \ thook a i Pain,2n,1 edi t i . r1 . L iut l i lL i ! i fEs lonc, Eclnb!Bh

r 9 . N i b o ) e t l I i ] i l 9 7 1 ) L ' . r r e s t h e s i e p a I l ' r . : u ] J t n . t D I eNla isof ncule. Frr rce: 59 9.+

. + 0 . Z h o ! L , J i a n 8 J ! { , W ! ( i ( , C a o X D 1 l 9 9 i r C h a n S c s o tc n d o E e n o ! s o p o i d r ) e p l ( e s c . i l e f l i n R P C L d u r i 8. . !p ! l ,cLure , rn. gesia. 5 l r - "n L i 1 l<u.h Paa. 1511):36 1 l

, 1 1 Z h o u L , \ / u a i c , C a o X D l l 9 . l 5 r R o c o i o p o l d p c p t i d e s o if a l i s i u . l e ! s r c t i c ! l a r i s p a r a S i E r n t o . e l l ! . r r s l r i e r a l i sIRPCL) in acup!r . ture anJlses r . , \ .ur l r i : r ! /e & f /e . torhcnrp.uri.s Reser/th 2A(2 ) : 89- | AA

, 1 2 . P r c c D D , R a f i i i A . W J t k n s l l t , B r c k i . g h i n r B 1 1 ' 1 8 , 1 rPsvcholrhys cJ J r r ys is o i icu )u. .1! r - " arra Eesia Panr. /9 j2 7 1 )

.11 Hrn lS ( l9 l l7 l rv lesol inrb jc nc! ra l oop o i rnJ l ]es i r n :-"n8o I, E..lcs 5, Cuc o AC, OtLoson Ll, ed\ r./!rr.pJ l,

Pai, R.s.ar.h and Thetapr relxnre /0 lteven l'r-.ss, N€i,

. + . 1 8 a d r y P t 1 1 9 9 3 ) A . L p L h . t D t e , I r i E E e t p a i n G a n dnus.u la l<eleta l pain,2rd e. / i r ior . Chrr .h i I L iv nEnone.td inburSh I20 ' , :1

. + i . l e B ; r s l l , C 3 l ! i n o B , V i l a n c u ! a L , C a d d e i 5 ( l 8 . i lPhvsio lo8l .a l approachcs to counter i r i tnL ion r )hef . i . re .a.l i : T r . k e l b a n k M D . C ! r z o n C , e d s . - 5 i . e t s t J . / o . e . /r r r /E€sra. W lc I Chi .hene 67 l0 l

. 1 { , L e B a E D , C h t o l r D . C l o t A M { 1 9 8 r l h e e . . o d i i 8 o ft h c r n r a l s t i m ! i b y d i i i u s e r o \ i o ! 5 n h i b L o n . o n i r o s(DNlc l . t i ia , Re5er/1h 210, 19.1 9! l

. + 7 . 1 e B d r D , V l d , , e u v a L , N i e r l C , B o l h a s s i r a D ( l 9 9 l lDi fn,se nor ors i rh ib iL. 'y .onl fo s {DNIC) i f an ma s a id inr\an A.DpDn.tLrc in Me.li.inc 9t2):17 55

. 1 8 . A n d e r s o n 5 A , E r i . s o n I l l o m B r e n E , f d q v i r l ( i ( l ! r l )E le. t roa. !p!n. iLrrc . [ i ra . t on pa n thres]o d f ,ea\ ! fed w thelectr .a l s t im! at on o i tc . r l . Bain. 6 l : 193 6

4 9 . C ] ] - " n E R 5 5 ( 1 9 8 9 ) N c ! r o p h y s i o o ! y o i . r c ! p ! . c L u r eaialScs a. In PoneD rz ts, stlx C, eds Si:i-.rrili. Ars.s o/A.upur. t ! ,e .Spr r le lver rg, Ber l . : j l9 J5

50.Ta<eshiSe C, N1!r r i M, ts . rch i5! ,1119l lo l Para e l nd v id!avar . t ion in ef ie . t i leners o l - " le . l foa. !puic tur . , morphinci , )a lSesie a.d d.6al fAC SPA aid ts rbol shment bv Dp h e i y l a l a n i f e . A . u p u n . t u t c & E l e . : u a t h e t d p e L t i c t/ier-.rr.h tr 251 6ll

5 1 . H a i J S , X i . C X , D i E I C , F r n S C ( l 9 8 , 1 1 H t h r n d l o $ ,i rcq!cncy e cct orc!pLrncLure inalB-"s i . are med at .c l bvd tr,: ent op oid peptiiei. Prin. 2lsupplencnt): 511

52 Picke, lR ( r 9e5i Low lo l t pu scd nr icro:nrp n nr ! l iL ofa in ica M.rnagenrent . ' l

5 l . S c o L t O 1 r 9 9 . 1 ) 5 - " r s o r t a n d m o t o r n c r ! c a c t , v r t o f. : K i rchen S, Bazi f S, cds. Clar ton ' \ E le. t toLh. t . t )y .

\ 'VB 5a!nde6 Co. . London:61 80- i .1 . Bal f i fos N1L (1995) Medicrnents v ! , ic r de.rease the in tak.

oi load. Pra.eedil?t oi Frlt t'inhellenl. Ab-.titr Car\rcst.Crcck MedicJ 5oc e lv to 'Obesi ly , A1he.s

5 5 . K a m i l J s T h ( l t r 9 5 ) l h e r o e o f h o n n o n e s . r . rneurotrr ,!fltlers n obesily. Pro.:e..inrAr or frtst Panhellenr(AbesiLr CohErcss. Cr-"ek 4,1€di .a l Socicty ior Obesi ty ,

5 6 . O d r u r r Y ( 1 9 r 6 ) P a l h o p h y s o l o S y o i t h e , r c ! p ! n c l o f er f - o a r m e n t . n : W a r r e n Z F . e d . H r n . l b a o k a i t r e d i c a lr .upun. tur . . Van Nonrrrd Rei fh i ld Co , New York:87 121

57 Ed.lman MC 11992) lltirht Ait, Btilliant Firc. Basi. Baok\Inc , r . l5A:49 60

58 Barchas lD, A<i l H, E l ior i ( ;R, Ho man RB, \ 'Vatson 5c(19781 t leh.v ioura l .euro.hemlnry: nc! ro lcE! ators rnr lbeh.r ourii st.t€s S..ien.-". 240:9t4 73

59. Andetroi F(i, flo!(liiL HK i I irllr r t he tit Dt1 ion.l I ale oi thebulbospin. l tereToni .ery i . re i ! .ur r ) ,sr . f i . N ' lT Prcss,

6(r . Ni - .u$,enhf !s R i l9Eir ahcrroarh i t . . tLue at the Lt t . in5pr i8crvcr laE. Bo in

l l l . I l o l . d a y J W , L o r H H . i C H ( l 9 i 8 r U . i ( t r e l ) e h a v i o 3c i iccts o i lpendorphln l r the i r 'e . r t l : , , rs , ip lo hfpolh. lam ci ! fc t lon. l r re -5. te, .e. :2 i 1525-.16

5l .Mel7 i .k l t , Casev KL ( l . l t , l j l 5- . fs . r ! , mol vat iona and. e n L f a . o n t r o l . l c t c r m n a n t s o i p a n r : K e i s h r l o J R ,Spr ngl ic d lL , Char cs Cl eds lhe s/n, ' se,se5, . l2 i - .1- l

MEDICAL

ACUPUNCTURE TREATMENTmak€s clinical and Economic sense

r Medica a.uoun.ture Clinics are run bv doctoBtrained inthe western, s(lentific use ofacup!ncture.

r They can often reduce co5ts and dea cheaply and effecrvelywithdifficut<rosrspecialty patient5.

a No expensive equipment is needed.

I Hospitak and GP'sthat run a.!pundure clinics have roundhigh levelsof dehandand patient3atisfaction.

Why not till yoor local nee.t?P.omoae Me.li.al A.upun.ture in Hospital and General

Pra.ti.e now!

THE BRITISH MEDICAL ACUPUNCTURESOCIETY was formed in 19a0 a5 an

association of medicalpractioners interested inacupuncture, There are nowover 1400 membels who useacupuncture in hospital or

gen€ral practice. Additionallythere are sections for dentists and

veterinary rurgeons,

The society i5 a registered charity with the aim ofpromotins the medkal use of a.upundur€. To this end,practical teaching courses on medicala(upuncture arearranged for dodo6 to disseminate an undeEtandingand appreciation of acupundure within the medicalprofession and to en(ourage its use.

The so.ietv's adminktrative officer is availableto dealwith any enquiries including those regardingmembership, couFes oftuit'on, text books, scientificmeetinss and thi5 journal.

PIeare address a enquiies to:Ihe British Medical Acupundure SocietyNelvton House, Newton LaneLower Whitley, WarringtonCheshir€ WA4 iUAlel: 01925 730727 Faxt 01925 730492E-lnail: Emaiadmin@aol.€om

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