By Russell J. Erickson, MD

Acupuncture is the third oldest healthcare art,
following faith healing and herbology. Its existence,
during 3,000 years, when many medical approaches, both
good and bad, have winked in and out of existence,
should give us cause to look seriously at its
contribution to healing, even though it is part of a
paradigm not indigenous to allopathic medicine and was
not invented in the USA. It rose in China instead of
Europe "because ancient Chinese science was empirical
with a distaste for theories and emphasized holistic
patterns, relationships, cycles and processes" (Bruce
Pomerantz). The fact that acupuncture is not a placebo
therapy is accentuated by its use in veterinary
medicine for 1,000 years in the Orient and 100 in
Europe, with increasing use during the last 20 years
in the United States, and by its effectiveness in
treating children down to infants. It appears
effective, especially in areas where allopathic
medicine is weak.

At present in the USA, roughly 3500 physicians and
11-12,000 non physician acupuncturists utilize this
medical art, with 40 acupuncture schools training
non-physicians, and about 500-600 physicians being
trained yearly to AAMA standards.

The physiology and biochemistry of acupuncture,
highlighted by a Medical Acupuncture Research
Foundation (MARF) conference (Arlington, Virginia,
November 1996), has been investigated extensively by
such workers as Bruce Pomerantz of Canada, Ji-Sheng
Han of China, Claudie Terral of France, and Daniel
Bossut of the USA.Howard Fields, USA, and others have
added knowledge about the nervous system function and
its relation especially to pain, Abraham Liboff to EM
studies, Owen Wilson to biophysical modeling of
acupuncture, Mark Friedman and Stephen Birch to
mathematical systems modeling, and Beverly Rubik has
centered discussion of acupuncture biophysics and
physiology. (1)

Many studies, especially from Bruce Pomerantz'
laboratory, and many centers in China and Japan, have
shown that acupuncture needling affects nociceptive,
proprioceptive, and autonomic nerve pathways to
increase enkephalins and dynorphins in spine and
mid-brain,and to raise endorphins in the
hypothalamus-pituitary region. The flow of enkephalins
in mid brain causes retrograde release of the
monoamines, serotonin and norepinephrine in the spine
which inhibit spinal pain transmission. Endorphins
inhibit substance P, involved in pain and
inflammation. (2) Data exists showing endorphins
present in immune system cells as well, where
acupuncture has also shown effects. Chinese studies
demonstrate c-FOS increase in effected brain areas
following acupuncture. c-Fos is a primary gene protein
and a marker for increased metabolic activity,
accompanying mRNA increases in brain cells which might
explain the long term effects, particularly of
repeated acupuncture sessions. (3) Involvement of mu
opioid receptors in periaqueductal gray matter were
shown to be involved in blood pressure response to
acupuncture in rabbit studies (4) and decreased EEG
abnormalities and siezures were accompanied by
decreased mRNA for proenkephalins as enkephalin
decreased and dynorphin increased in the hippocampus
accompanied brain normalization. (5) In addition to
opioid changes following acupuncture, laboratories in
China have demonstrated elevation of mRNA for
proopiomelanocortin, which is metabolized not only to
endorphin but to ACTH in equal proportion, perhaps
helping to explain part of the long term effect of
acupuncture beyond the rapid rise and fall of
endorphins. The hypothalamic arcuate nucleus, among
other areas is involved. (6) Other neuromodulators
could take part in acupuncture response.

Beverly Rubik and many others believe evidence points
to acupuncture effecting electromagnetic wave changes
in the body on a very fine level of nanoamperes and
microvolts; difficult to measure, and only now being
looked into with more precise instruments required to
circumvent much EM "background noise". Terral's
exacting work supports many prior more poorly
supported studies showing acupuncture points as
having less electrical resistance than surrounding
skin. (7) Becker and Selden, in their book on
electromagnetism and the body, mention the EM
possibility for acupuncture. (8) They are most
intent on describing the miniscule electrical flow
which bodies use for healing, where an initial
positive potential in shock state must convert to
negative to allow correct healing of bone and other
cellular tissue. The potential of this scientific
field is brought out by their studies of animals, such
as salamanders and worms, which are able to
regenerate body parts, but only if EM currents are
present; so miniscule that a platinum-silver wire
combination is enough to supply them. Acupuncture
might retune body processes toward normal with minute
EM flows, explaining the need for several treatments,
as healing of the body by itself is directed with
delicate nudges instead of exterior drugs and surgery.

Drs. LaRiccia & Alavi recently demonstrated by SPECT
scan that there is abnormal blood flow in some brain
areas of patients with chronic pain which returns to
normal when acupuncture takes away the pain. (1)
Studies from China and Japan have demonstrated
effectiveness in changes of blood flow, pain of all
types, changes in blood glucose levels in diabetes
and obesity, decrease in hyperprolactinemia and its
symptoms, leveling of hyper and hypothyroidism. In
China, it is common to do series of 10 daily
treatments for 2 to 4 courses, which we can't emulate
economically. Despite this, we should not denigrate
all data from the Orient. There is little evident
concept in Oriental countries that acupuncture
studies need randomization and blinding, as clinical
results in massive volume indicate to acupuncturists
that acupuncture effectiveness isn't even in question.
Part of the good results published there, above and
beyond the results found in the "West" to date might
be due to better training and technique, and part is
undoubtedly due to the ability to treat many times,
with accumulative effect. Part could be "placebo"
effect, but "placebo" effect extent itself is in
question. (9)

Acceptable refereed articles on acupuncture are
included below. Current desire in the USA is for
randomized studies of acupuncture treatment judged
against known effective "standard" accepted therapy.
Double blinded has been discarded--it is really not
feasible; single blinded is difficult. "Sham"
acupuncture as a control has been discarded as there
are too many acupuncture points, and the factor of
"diffuse noxious inhibitory control'" (DNIC) comes in,
demanding large numbers for statistical validity,
which is difficult, especially since there is no
source of funding for acupuncture study, other than
OAM, which is severally limited. (Catch 22)

A clinical literature review was done for a
conference on biomedical research on acupuncture in
Phoenix, Arizona, May, 1992, which reviewed many
articles. (10) Jenifer E. Cole should be mentioned for
her work on this project. Of mentioned significance
is work by Luo, Shen et al comparing 168 patients
with depression treated by electroacupuncture (EA)
with 139 controls treated with tricyclics. EA was as
effective without the side effects of medication.
Martoudis & Christofides calmed labor pains in second
stage in 87% of 168 women. Bullock, et al comparing 40
recidivist alcoholics treated with acupuncture to 40
with usual treatment, showing 21 of 40 completing the
program vs 1 of 40 controls, with controls having
twice the drinking after 6 months. Michael Smith
reported on 8,000 crack patients, with 85% of addicts
treated by acupuncture completing a program vs 35%
without. Kroenig and Oleson noted 86% of narcotic
addicted patients could be withdrawn in 2 to 7 days
with minimal side effects using auricular
acupuncture. Helms studied 43 women with dysmennorhea
using placebo acupuncture, standard and visitation
controls. Ninety % of acupuncture, 36% of placebo
acupuncture, and 18% of controls were relieved of
symptoms. Ellis, et al showed 9 of 10 elderly
patients with nocturnal voiding problems were improved
by acupuncture after 2 weeks vs 3 patients worsened in
the control group. Ballegaard et al randomized 49
angina patients to acupuncture and sham, with no
difference in nitroglycerine use, but a 50% decrease
in anginal attack rate in both (? DNIC effect in
sham), and a statistically significant betterment of
excercise tolerance in the acupuncture group. Two
studies on acupuncture use in asthma failed to show a
benefit, except for protection against
exercise-induced symptoms. Matched pairs with COPD
demonstrated benefit for acupuncture in symptom relief
(Jobst, et al). Zhao, et al, with 600 cases of
psoriasis, demonstrated cure in 62% with 20% relapse,
again amenable to therapy. (This requires many
sessions compared to Western approaches.) Mann, et al
treated knee rheumatoid arthritis with steroid
injection in one knee and acupuncture to the other,
finding acupuncture pain relief lasted 4 to 12 weeks
vs 2 to 6 for steroid, and better motion in the
acupuncture knee. Two of three randomized neck pain
studies (Coan, et al and Peng, et al) showed a benefit
for acupuncture, one (Petrie & Hazleman) did not.
Filshie, for 156 patients with malignant pain found
acupuncture significantly relieved 1/3 of tumor pain
and 2/3 of treatment-related or other pain. Several
studies with low numbers of pain condition patients
are also mentioned which showed no acupuncture
benefit. Lee and Liao, in 220 LBP patients, found 59%
relief lasting over 3 months. Headache study results
varied greatly, with numbers too small for statistical
significance. Dundee et al, in 3 publications, found
acupuncture handy for nausea and vomiting in varied
situations. Ho, et al, in a comparative study of 100
post-operative cases, found acupuncture as effective
as prochlorperazine for vomiting.

Lewith and Machin did a review article on randomized
trials studying the clinical effects of acupuncture.
(11) They found overall rates of 70% effectiveness for
acupuncture, 50% for sham acupuncture (DNIC?), and 30
% for "placebo". The majority of trials had low power
at a conventional rate of 5%.

Richardson and Vincent did a review of studies on
acupuncture treatment of pain. (12) They found the
overall quality of published reports to be poor,
though the group reviewed at least had a no treatment
control and involved larger numbers. They provide a
number of suggestions to be considered in doing
studies. They did conclude that there is good evidence
for the short term effectiveness of acupuncture in
relieving pain in each area examined, in the 50-80%
range. Insufficient data on followup limits knowledge
of longer term effect. The study by Coan, et al, where
acupuncturists were free to follow normal
individualized treatment practice, did show 58% with
pain down at 10 months. If one evaluates their list of
studies and picks out only those where 8 or more
treatments were given (more akin to traditional use
and in keeping with the aforementioned expectation of
build up of effect), rather than just one to a few
sessions, then the effectiveness of acupuncture
treatment stands out as very much better than the
controls.

terRiet et al, in a criteria based meta-analysis of 51
controlled studies on acupuncture for chronic pain,
using 18 predefined methodologic criteria, found the
quality of even the better studies to be mediocre,
with findings highly contradictory.(13) They note lack
of adequate numbers as a major problem (a strength of
China studies), loss of followup (a weakness of all
studies), and the effect of DNIC in needle controls.

Erickson evaluated all medical care a year before and
one after an average series of 6 acupuncture
treatments for 100 consecutive patients with chronic
pain of 6 month to over 10 year duration who had not
responded to usual medical care. Seventy three percent
, rated both subjectively and objectively by medical
care facility usage, responded, with 18% possibly
helped. Clinic visits dropped 26%, pain visits 52%,
and medication use over 50% for 6 months and 35% over
a year period. (14) A second series of 68 patients
with chronic unresponsive foot and ankle pain
demonstrated 31 cured and 19 with 75% pain decrease in
an average 4 treatments, on one year followup.(15)

Dr. Yutan, noting 80% of patients with facial
paralysis will recover with time, reported 718 treated
with acupuncture, had over 95% cure within 2 months,
judged clinically and by EMG, including those with
lesion at the level of petrosal nerve and geniculate
ganglion.(16)

Chou and Jiang treated 69 patients, with symptom
duration one month to one year, with 16 stones in
kidney and 62 in ureters (37 measured over 6 mm).
Fifty-nine percent were eliminated in two treatments,
with 23% moving down over 20 mm. (17) This was backed
by Liu and coworkers with 120 patients and over 82%
relief of stones. (18)

Lu reported 103 patients with postpartum urine
retention treated with 30 minutes of needling, with
85% urinating spontaneously after one or two
treatments (94% cured if symptoms less than 4 days).
(19)

Shi and coworkers reported 120 dysmennorheac women
with 87% improving markedly with acupuncture compared
to 32% of 44 given "Western" medication. (20)

Visetti and Costa stopped interoperative hiccups in
93% with auricular acupuncture at 3 points. If one
point (Oleson "diaphragm") only was used, 50% stopped.
(21)

Ballegaard and coworkers found, in 49 angina patients
treated with acupuncture, that exercise tolerance rose
slightly, while anginal attacks dropped 38% and
nitroglycerine use 58%. (22). This is backed by Wang's
group, comparing 39 acupuncture treated with 39
medically, randomized even-odd. Blood flow was more
normal, high glucose and lipids decreased, pain relief
was superior and abnormal ST EKG changes
subsided.(23)

Johanssen and workers found acupuncture increased
Bethel's Living Index from 71 in controls (usual PT &
OT) to 90, while reduced hospitalizations over a 3
year period saved $26,000 (US terms) per patient.
(24). The result is backed by Xian and Zhishun in 60
treated stroke patients vs 40 controls (25), Dong and
Yulin with 101 (26), and Yukang, et al in 120 (27).

Li, et al treated 31 patients with hyperprolactinemia,
compared with 15 controls with bromocryptine, with 17
cures (6 became pregnant) and 11 good effect, equal to
medication. Up to 40-50 treatments were used. (28)

Deluze and coworkers randomized 70 patients with
fibromyalgia (strict criteria) and found acupuncture
raised pain threshold 70% vs 4% in controls. (29)

Two recent reviews give estimates of acupuncture side
effects, with Rampes & James of England finding 100
serious side effects in 25 years literature search
(30), and a recent Scandinavian review estimating one
serious side effect per 4 to 5 years of practitioner
therapy.

I have mentioned only a few of 1542 recent acupuncture
references, some 0 to 400 of which I and colleagues
have reviewed the past 4 years. Many good studies
remain to be done, if biases can be overcome and
sources of funding for biostatistical and data
gathering help can be obtained. I have no doubt that
acupuncture is an effective healthcare approach, from
literature review, discussions with many excellent
clinicians, and my own clinical experience over 18
years of part-time acupuncture usage. It took me
years, while working without contact with other
acupuncture-utilizing physicians, to overcome the
emotional feeling that my results must be luck or
placebo, as needling results made no sense by US
training information.





Russell J. Erickson, MD
American Academy of Medical Acupuncture
Medical Acupuncture Research Foundation

Bibliography

1. Medical Acupuncture Research Foundation
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4. Ming, G et al. Involvement of mu opioid
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6. He, et al. Temporal alterations of
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19. Lu, X et al. A report on the treatment of
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20. Shi, X et al. An analysis on the therapeutic
effect of acupuncture at Sanyinjiao point for the
treatment of 120 cases of primary dysmennorhea. World
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21. Visetti, E. and Cost, P. Auriculotherapy for
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22. Ballegaard, S. et. al. Acupuncture in
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23. Wang, X-t. et al. Acupuncture treatment of
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28. Li, Y et al. Clinical study on the treatment
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29. Deluze, et al. Electroacupuncture in
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