J Appl Physiol

91: 2471–2478, 2001.

Biomechanical response to acupuncture
needling in humans

Departments of Neurology, 2Orthopaedics and Rehabilitation, 3Medical Biostatistics, and
Radiology, University of Vermont College of Medicine, Burlington, Vermont 05405
Received 23 March 2001; accepted in final form 25 July 2001

Langevin, Helene M., David L. Churchill, James R. and/or pistoning (up-and-down motion) of the needle.
Fox, Gary J. Badger, Brian S. Garra, and Martin H. Needle manipulation can be brief (a few seconds), pro-
Krag. Biomechanical response to acupuncture needling in longed (several minutes), or intermittent depending on
humans. J Appl Physiol 91: 2471–2478, 2001.—During acu- the clinical situation (33). Even when electrical stimu-
puncture treatments, acupuncture needles are manipulated
lation is used (a relatively recent development in the
to elicit the characteristic “de qi” reaction widely viewed as
essential to acupuncture’s therapeutic effect. De qi has a
history of acupuncture), a certain amount of manual
biomechanical component, “needle grasp,” which we have needle manipulation is usually performed immediately
quantified by measuring the force necessary to pull an acu- after needle insertion (6, 40).
puncture needle out of the skin (pullout force) in 60 human Traditionally, manipulation is performed to elicit the
subjects. We hypothesized that pullout force is greater with characteristic reaction to acupuncture needling known
both bidirectional needle rotation (BI) and unidirectional as “de qi.” De qi has a sensory component perceived by
rotation (UNI) than no rotation (NO). Acupuncture needles the patient as an ache or heaviness in the area sur-
were inserted, manipulated, and pulled out by using a com- rounding the needle and a simultaneously occurring
puter-controlled acupuncture needling instrument at eight biomechanical component that can be perceived by the
acupuncture points and eight control points. We found 167 acupuncturist (3, 6, 10, 16, 33). We refer to this com-
and 52% increases in mean pullout force with UNI and BI, ponent as “needle grasp.” During needle grasp, the
respectively, compared with NO (repeated-measures ANOVA,
acupuncturist feels as if the tissue is grasping the
P ⬍ 0.001). Pullout force was on average 18% greater at
acupuncture points than at control points (P ⬍ 0.001). Needle needle such that there is increased resistance to fur-
grasp is therefore a measurable biomechanical phenomenon ther motion of the manipulated needle (6, 10, 38, 40).
associated with acupuncture needle manipulation. This “tug” on the needle is classically described as “like
a fish biting on a fishing line” (48). Needle grasp can
acupuncture meridians; connective tissue range from subtle to very strong, with pulling back on
the needle resulting in visible tenting of the skin (16,
21). During acupuncture treatments, needle manipu-
ALTHOUGH ACUPUNCTURE IS INCREASINGLY USED for the lation is used to elicit and enhance de qi, and de qi is
treatment of pain and other conditions (27, 37), the used as feedback to confirm that the proper amount of
rational basis underlying its use remains unclear (2). needle stimulation has been used.
Western medical experts have been inherently skepti- De qi is widely viewed as essential to acupuncture’s
cal of acupuncture’s therapeutic value. One reason is therapeutic effectiveness (6, 10, 16, 23, 33, 40). Docu-
that it seems very unlikely that the simple act of mentation of de qi has been used as a criterion for
inserting fine needles into tissue could elicit any effect evaluating the adequacy of both manual and electrical
at all, let alone wide-ranging and long-lasting thera- acupuncture treatments in clinical trials (13, 46). Nee-
peutic effects. Hypodermic needles are routinely used dle manipulation, de qi, and needle grasp, therefore,
in Western medicine, and their insertion into the body are potentially important components of acupuncture’s
is not considered therapeutic. Acupuncture needles are therapeutic effect, yet the mechanisms underlying de
of a finer gauge than even the finest needles used for qi and needle grasp are unknown.
intradermal injections, and acupuncture rarely results As a first step toward understanding the physiolog-
in a single drop of blood being discharged. ical and therapeutic significance of de qi, we have
What is not widely appreciated by nonacupunctur- quantified needle grasp by measuring the force neces-
ists, however, is that acupuncture typically involves sary to pull an inserted acupuncture needle out of the
manual needle manipulation after needle insertion (3, tissues (pullout force). We hypothesized that pullout
6, 16, 33, 40). Manual needle manipulation consists of force is greater with two different types of needle
rapidly rotating (back-and-forth or one direction)
The costs of publication of this article were defrayed in part by the
Address for reprint requests and other correspondence: H. M. payment of page charges. The article must therefore be hereby
Langevin, Dept. of Neurology, Given C423, Univ. of Vermont College marked ‘‘advertisement’’ in accordance with 18 U.S.C. Section 1734
of Medicine, Burlington, VT 05405 (E-mail: hlangevi@zoo.uvm.edu). solely to indicate this fact.

http://www.jap.org 8750-7587/01 $5.00 Copyright © 2001 the American Physiological Society 2471

the acupuncture point’s meridian and as far as possible from ation to avoid possible discomfort due to cessation of anti. informed consent was control points. this will demonstrate that needle manipulation has measurable biomechanical effects. Needle-insertion depth was standardized and based on tissue measurements made by ultrasound. CA) equipped with a 7-MHz proportional measurements (e. tendons) and chine (Acuson.org .” we also hypothesized that pullout force is greater at classically defined acupuncture points than at nonacu- puncture control points.g.5 cm. or NO). For each location. neuromuscular disease. each subject was randomized into tion type (NO. General Clinical Research Center between June 2000 and December 2000. Protocol summaries were mailed after used to refer to a corresponding pair of acupuncture and to volunteers for review. one of three experimental groups. the nearest bone and joint. subjects were neither told nor able to participated in one testing session lasting 2–3 h. Sanyinjiao (Sp6). Qinling Study Site and Participants (Ht2). M. bones. bleeding disorder. where S was the slight depression or yielding of tissues. a similar “dummy” procedure was performed and then disregarded. After consenting. The term “acupuncture/control location” is here- Institutional Review Board. The disk was 2 cm in radius for points areas tested. collagen for acupuncture point and control point.. Approximate position was determined aging was performed with an Acuson 128 ultrasound ma- in relation to anatomic landmarks (e.. and Chengshan (B57). Each acupuncture point was therefore Study Protocol paired with a corresponding control point on the opposite side Study protocol was approved by the University of Vermont of the body. Eight traditional acupuncture point locations were inves. we carried out an experi- ment in which normal human subjects received differ- ent types of acupuncture needle manipulation at eight acupuncture points and eight corresponding control points. Testing was not scheduled during menstru. BI. Zusanli (St36). muscle). For each acupuncture/control location. To test these hypotheses. Zhongdu (GB32). obtained on the day of the study. The following acupuncture points were used in this study: Hoku (LI4). target needle inser- tigated (Fig. Female volunteers were excluded if they was marked on the perimeter of the disk at a 45° angle from were pregnant. located on the forearm and lower leg and 3 cm in radius for histamine medications were asked to discontinue their use 3 points located on the upper arm and thigh. acute or chronic corticosteroid therapy. the perimuscular fascia is visible as an echogenic line ture points total). subcutaneous tissue thickness measured by ultrasound at J Appl Physiol • VOL 91 • DECEMBER 2001 • www. Since de qi is tradi- tionally believed to be greater at “acupuncture points. On the side selected vascular disease. For each location. Within the area delin. With ultrasound im- were identified and marked with a skin marker (16 acupunc. If proven true. and for control point. Kongzui (Lu6). feeling for a point and was calculated as: D ⫽ S ⫹ 1.jap. METHODS Fig.2472 BIOMECHANICAL RESPONSE TO ACUPUNCTURE NEEDLING manipulation commonly used in acupuncture practice [bidirectional (BI) and unidirectional (UNI) needle ro- tation] than with needle insertion with no manipula- tion (NO). used for both acupuncture point and corresponding control puncture point was determined by palpation. fraction of the distance linear array transducer.g. perpendicular to the skin. Abbre- viations in parentheses correspond to acupuncture meridians and The study was conducted at the University of Vermont point numbers (6). These measurable effects. The same needle depth (D) was eated by these landmarks. Ultrasound im- traditional methods. manipulation. Healthy volunteers aged 18–55 yr were invited to participate. Quchi (LI11). The transducer was always held between wrist and elbow creases) (6). ture point. aging. a pair of corresponding tion depth was determined based on ultrasound measure- acupuncture points on the right and left sides of the body ment of subcutaneous tissue thickness. Acupuncture points were identified by an separating two tissues of different echogenicity and com- experienced acupuncturist (H. A computer-controlled acupuncture needling instrument was fabricated and used to perform all needling procedures (needle insertion. 1). and written. together with the historical importance of this technique. 1. or UNI) was being performed. UNI. These groups differed only Determination of Needle Insertion Depth in type of needle manipulation used (BI. will suggest that needle manipulation may indeed play an impor- tant role in acupuncture therapy. Volunteers taking anti-inflammatory or anti. and pullout) as well as measurement of pullout force. during see or hear any indication of which side was used for each which a total of 16 points on the body received acupuncture point (acupuncture and control) and which needle manipula- needling. Each enrolled volunteer Throughout testing. Mountain View. the precise position of each acu. a disk-shaped template was centered on the extensive scarring or dermatological abnormalities in the acupuncture point. Langevin) according to pressibility (subcutaneous tissue vs. On the side selected for acupunc- inflammatory medication. The control point days before testing. Exclusion criteria were a history of right and left sides of the body were then randomly selected diabetes.

Just enough force is applied acupuncture points from seven different acupuncture text. 12. to maintain light contact with the skin. B: needling instrument in use. In at each acupuncture point in all subjects. 47) and averaging the suggested ically isolated from the skin-contacting foot. Fig. significant tissue compression artifact was found. evaluation tests. From left to right: cutaway view with needle extended. BIOMECHANICAL RESPONSE TO ACUPUNCTURE NEEDLING 2473 the acupuncture point. To perform a pullout test. Applying too much pres- subjects (8 men and 8 women). following manner. In loadcell readings are not affected by pressure against the a pilot study of subcutaneous tissue measurements in 16 skin by the foot of the instrument. with the instrument in its final orientation compensates for both of which are controlled by the computer. This because the weight of the needle rotation motor and needle system consists of a hand-held needling instrument (Fig. The loadcell is phys- books (1. and. and therefore upper and lower limits of the listed ranges for each point. the needle is robotically advanced into the tissue tissue on the needle. J Appl Physiol • VOL 91 • DECEMBER 2001 • www. All needling procedures (insertion. can compress the underlying tissue and could using the above formula fell within the recommended ranges potentially influence how the tissue responds to needling. pullout. grip (which are mounted to the loadcell’s live side) is signif- a personal computer fitted with a servomotor controller. This formula for needle depth was against a subject’s skin in the appropriate location and ori- based on compiling needle depth guidelines for the listed ented perpendicular to the skin.jap. and within this range no Needling system. The first motor this gravity-induced loadcell signal such that only those is coupled to a ball leadscrew and generates linear needle forces exerted by the tissue on the needle are recorded. pulled out of the tissue. The investigator holds the instrument after a 10-s delay. and pullout-force measurement) were After the instrument has been properly positioned and performed by a computer-controlled acupuncture needling oriented but just before the needling procedure has been system. needling procedure is initiated.org . The icant compared with typical pullout force. rotated to perform manipulation (if called for). Taring the system needling instrument contains two miniature servomotors. cutaway view with needle retracted. 2. however. This ensured consistent experimental conditions and initiated. needle depth determination sure. through a hole in the instrument’s skin-contacting foot (Fig. the loadcell reading is tared. Inset shows needle in extended position. 2). The second motor Once the instrument has been positioned and the loadcell generates needle rotation (manipulation). Under the computer’s strain-gauge loadcell measures all axial forces exerted by the control. 3. the system operates in the 2. motion (needle insertion and pullout). side view. we found that the investigator could easily Acupuncture Needling maintain skin contact without causing visible skin compres- sion throughout a pullout test. 6. nipulation. and custom-written control and data acquisition software. ma. This is necessary eliminated many potential sources of investigator bias. inset). A 500-g capacity tared. 39. 33. A: design schematic of acupuncture needling instrument.

Be. These automatically identified and saved as the pullout-force out- parameters were determined by observing and simulating come measure (Fig. Between puted based on the method described by Kendall and Stuart test points within the same subject. continuously recorded the needle force detected by the load- tions/s. which correspond to the antilog of the avoid any visible compression of skin by the instrument arithmetic means of the log-transformed data. and body needle manipulations corresponding to “moderate” practice mass index (BMI) by using ANOVA. depth. Needle-manipulation techniques vary widely in clinical practice. Subjects randomized to the three needle-manipulation lation to rapid and forceful needle movements. Outcome Measure pendently set. domized to one of the three needle-manipulation types (whole ture point and to minimize repositioning of the subject be. were performed by using Fishers least signifi- (Seirin. insertion depth between acupuncture and control points and ture/control location was entered into the computer. Pairwise comparisons among means. and Kruskal- were chosen for BI and UNI.jap. 40. ized to right or left side for each acupuncture/control location dled before control points within each acupuncture/control within subjects.g. respectively. After ultrasound imaging was per. 3): needle the entire needling procedure. gender. plot) and acupuncture and control points (subplot) random- tween marking and needling. no nee- dle manipulation. the data acquisition system insertion speed was 10 mm/s. unidirectional rotation. Japan) 30. dwell time. used to assess differences in mean pullout force and needle- formed. 3. Shimizu. In this study. pullout speed) can be inde. Graphical descriptions of needling procedure types and examples of corre- sponding pullout force measurements.org . Experimental needle insertion depth at each control point was set according design was treated similar to a split-plot with subjects ran- to ultrasound measurements at the corresponding acupunc. Repeated-measures ANOVA was Needling protocol. all parts of the instrument that came in computer controlled. rotation speed. Langevin). Data corresponding to pullout mm in diameter was mounted in the needling instrument. all motion parameters (e. All means presented for pullout force enough pressure to maintain light contact with the skin to are geometric means. insertion speed. types were compared with respect to age. M.25 cant difference (LSD) test. In this study.. The peak force occurring during the pullout phase was 10 s after manipulation. the number of needle rotations for needle manipulation was 16 clockwise for UNI and 16 The needle-grasp component of de qi is an increase in the alternating clockwise and counterclockwise cycles of four gripping of the acupuncture needle by local tissues. rotation speed was 8 revolu. All other needling parameters with the force outcome measure quantifies the force required to over- exception of needle insertion depth (see above) were held come the attractive forces between needle and tissue. amount of rotation. Fig. or 50 mm in length and 0. ␹2-tests. Approximate (verified by an observer). J Appl Physiol • VOL 91 • DECEMBER 2001 • www. During constant across all points and all subjects (Fig. Because the needling instrument is tween subjects. Needle-motion parameters are listed in text. acupuncture points were nee. force were log transformed before analysis to satisfy the Skin at each point was disinfected with alcohol. Because across the three needle-manipulation types. For each point.2474 BIOMECHANICAL RESPONSE TO ACUPUNCTURE NEEDLING Needling parameters. Peak force detected during needle pullout was taken as the pullout force. direction of rota- tion. BI. NO. the appropriate insertion depth for each acupunc. 3). Statistical analyses were performed using SAS statisti- disinfected by submerging in isopropyl alcohol for 30 s. These differed only in the needle manipu- lation used. UNI. pullout speed was 5 mm/s. Wallis tests. needle dwell time was 2 s before manipulation and cell. a new sterile disposable needle appropriate. Top: programmed linear insertion/retrac- tion (dashed line) and rotary manipula- tion (solid line) motion of acupuncture needle for the three experimental groups. bidirectional rota- tion. Activation of a push-button switch standard errors associated with geometric means were com- initiated the needling procedure as described above. The needling normality and homogeneity of variance assumptions associ- instrument was then held by hand against the skin using just ated with ANOVA (5). needle manipulations performed by an acupuncturist trained in a variety of different acupuncture needling techniques Statistical Methods (H. ranging from almost no manipu. insertion contact with the subject or the needle were steam sterilized. Pullout- rotations each for BI. when location. cal software. Bottom: examples of the re- sulting axial force on the needle. the instrument was (18).

5. F(1. Mean pullout force at acupuncture points was 63.3 ⫾ 8. P ⫽ 0. and UNI (C).5 ⫾ 2.41 mm. significant differences were found among the manipulation types [F(2. St36..001].4 g. P ⫽ 0. 4. completed the testing protocol.1 ⫾ 10. control point: 87. Our measurements of pullout force are the first tical significance (P ⬍ 0.48 for needle manipulation by point-type interaction]. The remaining 60.1 g.3 kg/m2. control) [F(2.001. P ⬍ 0.50 mm. Fig. 4B].19) ⫽ 9.2 ⫾ 7. is graphically displayed in Fig.57) ⫽ 62.2 ⫾ 0.4 g. Mean pullout force was also significantly greater at acupuncture points than at corresponding control points [F(1.6 ⫾ 0. Height of bars represents geometric means. points than at control points in seven out of the eight DISCUSSION locations tested (Ht2.9. Means are significantly 0. and B57). Pairwise compari.8 ⫾ 2. UNI: average pullout force was observed at acupuncture 22. P ⬍ 0. and the latter was significantly greater than that for NO (36. Conversely. P ⬍ 0. P ⬍ acupuncture points and control points (B). a greater types [NO: 21.0. F(1. Acupuncture and control points also differed different across the three needle-manipulation types within both significantly within NO [acupuncture point: 38.5 ⫾ 5.001 for acupuncture points and F(2. 4A].57) ⫽ 49. Fig.001.57) ⫽ 18. Mean pullout force (⫾SE) for UNI (97. insertion depth across the three needle-manipulation trol locations was not the aim of our study.07. 0. Sp6.05). LI4. There was no evidence that differences between nee- dle-manipulation types were dependent on point type (i.9 ⫾ 0.4. BI [acupuncture point: 60. point: 51. the primary outcome measure.001) different between needle-manipulation types (A) and between icantly different from the others (Fishers LSD.35]. BIOMECHANICAL RESPONSE TO ACUPUNCTURE NEEDLING 2475 RESULTS Study Participants Sixty-one volunteers were enrolled in the study. P ⫽ 0. Significant differences in pullout force were observed across the three needle- manipulation types [F(2.2 g. Within acupuncture and control points. P ⫽ 0.e. There were no significant differences with respect to these subject characteristics between the groups of subjects randomized to the three needle-manipulation types. Means are also signifi- cantly different between acupuncture and control points with NO. Means and SD for age and BMI of participants that completed the study were 37.2 yr and 26. F(1. P ⬍ 0. respectively.001 for control points].8 g) (Fishers LSD. control.7 g).5.5 ⫾ 2.7 ⫾ control points and acupuncture points (C).3 g. Fig. BI: 22. differences in pullout force between acu- puncture and control points not were dependent on the type of needle manipulation.0 g.039].37 mm. with three (Ht2. One female participant withdrew during testing because of discomfort associated with the testing procedure. control bars represent SE. P ⬍ 0.05). Fig.7 ⫾ 1. Error 0.19) ⫽ 26.8.19) ⫽ 4.57) ⫽ 75.5 g) was significantly greater than that for BI (55. F(2. consisting of 38 women and 22 men. Means are significantly (P ⬍ sons indicated that each manipulation type was signif.3 g compared with 53.57) ⫽ 1.5 ⫾ 0.7 ⫾ 1. LI11. P ⬍ BI.5 ⫾ 5.9 ⫾ 2.57) ⫽ 0. Secondary analyses were performed comparing pull- out force within needle-manipulation types and within point types (acupuncture vs. There was no significant difference in mean needle- Although the testing of individual acupuncture/con. Lu6. and Sp6) achieving statis.0 g at control points.05). control point: 34.007] and UNI [acupuncture point: 109.73. a biomechanical aspect J Appl Physiol • VOL 91 • DECEMBER 2001 • www.0.jap. acupuncture vs. Pullout force measurements. 4C). 1. quantification of needle grasp. Pullout-Force Measurements Pullout force.org . 4. LI11.

A frequently stated opinion is that needle continuously as needle rotation proceeds. essential to the therapeutic effect of acupuncture. in which needle grasp (Fig. Be- dle grasp. We (19) observed elastic and collagen fibers that were found 167 and 52% increases in pullout force with UNI entwined around the needle. However. Tissues likely volving winding quickly can result in strong mechani- involved in needle grasp are therefore the skin and/or cal coupling between needle and tissue. but unwinding is where no skeletal muscle is present (such as at the incomplete. and removal. is likely to occur as a compo- nent of the triple inflammatory response to the injury created by the acupuncture needle. In a study using rat tissue and BI. Contraction of connective tissue has not been studied in relation to acupuncture but is a potentially impor- tant component of the needle-grasp phenomenon. whereas needle grasp is ob- served within seconds of inserting and manipulating the needle. several hundred grams represent substantial loads although contraction of muscle may occur during nee. 5A). with UNI. Possible mechanisms importance of this effect is that. explants.2476 BIOMECHANICAL RESPONSE TO ACUPUNCTURE NEEDLING of the characteristic de qi reaction widely viewed as insertion. respectively. cause of its self-amplifying nature. compared with NO. 45). these An estimate of needle torque could be obtained in our results indicate that needle grasp is strongly influ. Figure 5 shows the amount of torque nonquantitative evaluation of electromyographic activ. gen around the needle (21). Increased tissue turgidity because of the triple inflammatory response is therefore unlikely to be the mechanism underlying needle grasp. Together. human subjects by measuring the electrical current enced by needle manipulation and that this effect is not delivered to the motor during the different manipula- unique to acupuncture points. developing at the needle-tissue interface during UNI ity during acupuncture needling. With BI. Needle ma.jap. Increased tissue turgidity. Whether such rapid cytoskeletal changes in connective tissue fibroblasts can themselves result in measurable contractile forces at the tissue level is at the present unknown. given the small diameter (250 ␮m) of the needle. 5B). occurring over seconds to min- utes and involving polymerization of soluble actin and formation of actin stress fibers. How. The potential subcutaneous connective tissues. Although we also found an dle after needle rotation. the only published study supporting this view is a sively increased. muscle contraction is not the primary mech. Kimura et al. the magnitude of this winding of connective tissue is consistent with our difference was much smaller than the difference finding of greater pullout force with UNI than with BI. Needle grasp can be observed at locations winding alternates with unwinding. 40).org . In an electron microscopy Fig. tion procedures. Con- traction of fibroblasts. resulting in a gradual build up of torque in wrist) and on palms and soles where there are no the tissue (Fig. 5A) and BI (Fig. with visible winding of colla- 18% difference in mean pullout force between acupunc. the ear- liest evidence of arteriolar dilation leading to protein extravasation during the triple response occurs 10–15 min after injury (9. 16). the grasp is caused by a muscle contraction (15. We typically observed that. With BI. 5B). contraction. we observed a pronounced increase in the nipulation increased pullout force at both acupuncture thickness of subcutaneous tissue surrounding the nee- points and control points. manipulation. final torque at the end of each rotation cycle progres- ever. 5. and winding of tissue around the needle during needle rotation. Winding of connective tissue around the needle dur- ing needle rotation is another possible mechanism con- tributing to needle grasp. is well documented in vitro (20). The mechanism underlying needle grasp is currently the torque required to rotate the needle increased unknown. arrector pili smooth muscles. We torque during UNI is consistent with tissue winding believe that muscle contraction is not the source of around the needle (Fig. once the needle has involving these tissues include increased turgidity. we propose that needle grasp. It is therefore likely that. Example of the amount of torque developing at the needle- study of debris found on acupuncture needles after tissue interface during UNI (A) and BI (B) in a human volunteer. J Appl Physiol • VOL 91 • DECEMBER 2001 • www. a mechanism in- anism responsible for this phenomenon. Tenting of skin observed A mechanism involving winding of tissue is attrac- during needle grasp when the needle is pulled back tive because this would greatly amplify the friction also suggests that layers superficial to muscle are force between tissue and needle (17). The continuously increasing was subjectively rated by the acupuncturist (34). resulting from extravasa- tion of protein-rich fluid. Pullout forces of grasping the needle (21. caused by manipulation of the needle. A mechanism involving ture points and control points.

and acupuncturists The difference between these two levels of effects fits modify these techniques according to the patient’s age. a grasp has been described in acupuncture textbooks credible sham procedure but did not aim to test for for over 2. Elim- would be expected to occur wherever connective tissue ination of feedback-driven adjustments in needling is present but may also vary depending on local qual- technique was necessary in our study to test our hy- itative or quantitative tissue differences. 30. nonacupuncture points. the therapeutic effect of needling An important limitation of this study is that a nonacupuncture points appeared either equal to that of cause and effect relationship between pullout force acupuncture points or intermediate between that of and therapeutic effect has not been established. 32) and various types of nerve gratefully acknowledged. 26. appears to be more subtle. on the other hand. 47). poorly controlled. We chose our substrate on which this technique is applied (the tissue needling parameters to be consistent with acupuncture into which the needle is inserted). 39. tendon) (6. connective tissue can wind around the needle at These effects may be prolonged and explain the per. gene ex. other hand. in a clinical setting. Attempts to identify unique anatomical and/or We thank Jason A. This needling acupuncture points and that of nonneedle study for the first time demonstrates a link between placebos (2. On the extracellular connective tissue matrix. Hamill is also lar bundles (4. 29). In addition. (between muscles or between muscle and bone or stream effects ranging from cell contraction.” or to the gen. These clinical be used in clinical trials of acupuncture. dling techniques are used (22). A remove an important therapeutic component. although many of these trials were puncture would be valuable in future studies. ful downstream effects at acupuncture points via Our results indicate that the effect of needle manip. acupuncture points. Some differences nevertheless necessarily ex- needle manipulation appears to have pronounced ef. unteers. no histological study RO1AT-00133 and conducted at the University of Vermont General so far has compared acupuncture points with control Clinical Research Center at Fletcher Allen Health Care supported by points by using quantitative morphometric methods. Compar- number of early clinical trials of acupuncture com- ison of clinical outcomes obtained with acupuncture pared clinical outcomes with needling of acupuncture needling performed by our instrument vs. W. R. BIOMECHANICAL RESPONSE TO ACUPUNCTURE NEEDLING 2477 become mechanically coupled to the tissue. Doran for assistance Various histological structures such as neurovascu. The technique of practice. a wide variety of nee- effect.org . resulting in deformation of some studies (8. of these effects in future studies may eventually lead controlled clinical trials have compared the needling of to insights into acupuncture’s therapeutic mecha- acupuncture points with sham procedures using no nisms. Substrate ture. needle placement (acupuncture vs. In the shorter term. Reviews of these studies concluded that. 33). J Appl Physiol • VOL 91 • DECEMBER 2001 • www. palpation of tissues. This is con- potheses objectively but might.Weld for recruitment of vol- meridians so far have been mostly unconvincing. first step toward determining the biological and clin- ture points and nonacupuncture points. with a mechanism involving tissue winding. acupuncture points and meridians are formation may be transduced into local cells present frequently located along connective tissue planes within connective tissue with a wide variety of down.jap. 42. 44). Recent well. 25. those points. 43). since neurovascular bun- plexing claim that acupuncture treatments can have dles are located along connective tissue planes. Yandow for assistance in conducting the study physiological properties of acupuncture points and and preparing the manuscript. Apparent therapeutic effects acupuncture needle manipulation and biomechanical observed at control points were attributed to the “non. 31) but not in others (28. stimulation of these structures by the mechanical ulation on pullout force dominates over the effect of matrix deformation caused by tissue winding. Winding underlying condition. allowing controlled a technique (needle manipulation) vs. 36). Riesner and Richard A. Needle grasp may therefore be pression.000 years (27a). endings (7. This matrix de. 14. manual acu- vs. also provide important biological markers that can lation at nonacupuncture points (24. subsequent Skin electrical conductance has been found to be needle manipulation (either rotation or pistoning) may lower at acupuncture points than at control points in pull on collagen fibers. ical significance of this phenomenon. these same effects may needling or minimal needle insertion without manipu. 11. and Adam D. 35) have been reported at This study was funded by the National Institutes of Health (NIH) Center for Complementary and Alternative Medicine Grant no. These biomechanical events are specific physiological effect of needling. the impact of the insertion and manipulation of needles. Developing an understanding inhibitory controls or DNIC”) (42. nonacupuncture The use of a computer-controlled instrument to per- point). In the clinical situation. with illustrations. events in the tissue. slightly greater at acupuncture points because more and neuromodulation of afferent sensory input (21). The difference in the magnitude of these effects form all acupuncture needling procedures is an impor- may correspond to the difference between the impact of tant and novel aspect of our study. the therapeutic effects lasting days to weeks and even same amount of needle grasp may have more power- permanently. This study constitutes a differences in therapeutic response between acupunc. potentially associated with long-lasting cellular and eralized effect of noxious stimulation (“diffuse noxious extracellular effects. secretion of paracrine or autocrine factors. However. and sensa- of connective tissue in response to needle rotation tions obtained during the needling itself (6. ist between our study protocol and clinical acupunc- fects no matter where the needle is placed. The ongoing support of Dr. Gale A. NIH Center for Research Resources Grant M01RR-00109. Needle trials showed the effectiveness of acupuncture vs. sistent with available evidence from clinical trials.

Stux G and Pomeranz B. by Bertschinger R. Am J Chin Med 4: China: People’s Republic Publishing House. Beijing. Choi C. Kolodney MS and Wysolmersky RB. 1976. Electroacupuncture. General Pathology (6th ed. Wiseman N. Essentials of Chinese Acupuncture. Glaspy J. Am J Chin Med 20: 25–35. Electron microscop. 1979. chronic pain: a criteria-based meta-analysis. Shanghai. J Cell Biol 117: 73–82. Physicians. Churchill DL. studies. Varela M. 15. Lao L. J Clin Epidemiol 20. Isometric contraction by 11: 1191–1199. Szopinski J. Pain 86: 217–225. Acupuncture. Nouv Presse Med 4: 2021–2026. how? Semin Clin Neuropsychiatry 4: 167–175. Am J Chin Med Press. ans. Maisonneuve. work and. 66–71. 1992. 1987. JAMA 284: 2755–2761. 1987. ment. 18. 45. Ohnishi M. Bases experimentales de l’analgesie acupuncturale. Churchill Livingstone. Box GEP. Electroacupuncture for control of myeloab- needle grasp in acupuncture. 7. 1994. The Golden Needle and Other Odes of Traditional surgery: a placebo-controlled trial. Basics of Acupuncture (3rd ed. Dung HC. 2001. Bossy J. IEEE Trans menters. 1973.] Acupuncture. Arch Otolaryngol Head Neck Acupuncture. Cheng X. Ditchburn FG.] J Appl Physiol • VOL 91 • DECEMBER 2001 • www. 1601. 38. Englewood Cliffs. 1982. Langenberg P. A trial method for assessing the 1999. Brookline.Lu HC (Translator). 1987. 1996. 3: 347–358. Kleijnen J. Hua Berlin: Springer-Verlag. I. 1991. 1997. Kumar V. Hays RD. 35. ment Med 2: 23–25. circa 300 BC. Morphological data concerning the acupuncture points Oriental Heritage. 1995. Senelar R. Noordergraaf A and Silage D. WA: Eastland. Loitman JE. The correspondence be- of Chinese Acupuncture. and Renwick GJ. Introduction to Meridian Therapy: Classical Japa. IEEE Trans Biomed Eng 22: 9. Nouveau traite d’acupuncture. Am J Acup 12: 139–143. Pain 16: 111–127. Langevin HM and Vaillancourt PD. FASEB J 15: 2275–2282. Yang J. The neurological mechanism of and Shekelle PG. Investigations 30. 1983. Bergman S. Pain 24: 1–13. An Outline 26. Liu KY. and Noguchi E. China: Foreign Language tween some motor points and acupuncture loci. Lewith GT and Machin D. Silvers M. Toda S. McCarroll GD and Rowley BA. Albert PS. Hadhazy VA. their relationship to known neural structures. Wenger N. Kendall MG and Stuart A. Placebo controls for acupuncture study. Edin- 22. Shanghai Medical University. 28. 46. Oda H. Canada: Academy of 4. Jadad AR. Su Wen. 2000. 1975. 1984. J Tradit Chin Med 5: 289–292. and Becker RO. Brookline. Chi- 29. Acupuncture Energetics-A Clinical Approach for trial. 1973. 2000. Yellow Emperor’s Classic of Internal Med- China: Foreign Language Press. 1991. 1987. and Nanjing Colleges of Traditional puncture and hypnosis. ridians and Points. and ity produced locally by acupuncture manipulation. lative chemotherapy-induced emesis: a randomized controlled 16.org . Kuroiwa K. and Oswald R. apeutic effect of acupuncture. Vincent CA and Richardson PH. Charac. 19. J R Soc Med 88: 199–202. Basis of Disease (6th ed. In: Niboyet JEH. IEEE na: Foreign Language Press. Tohya K. A Relationship Between Points of Meridians and Periph- Acupuncture loci: a proposal for their classification according to eral Nerves: Acupuncture Anaesthetic Theory Study. 27. 2000. Tisbury: Element Books.). Terral C. Acupuncture wins BMA approval. 1977.). and Ber. Beijing. The Academy of Traditional Chinese Medicine. Biomed Eng 26: 177–182. Hamilton GR. Ciczek LSW. vol. Pain management: beyond pharmacology to acu- 3. ZX. Fundamentals of Chinese Bensky D and O’Connor J. Marino AA. adequacy of acupuncture treatments. 183–195. Seattle. Beijing. Shanghai Institute of Physiology. Vancouver.2478 BIOMECHANICAL RESPONSE TO ACUPUNCTURE NEEDLING REFERENCES 25. and Boss K. MA: Paradigm. Philadelphia. Soulie de Morant G. Shanghai. 1995. 1978. 36. Electrical cor- Experientia 51: 328–331. Schiessl N. Comprehensive Text. man B. Seattle. Hunter WG. WA: Eastland. 1986. and of morphological structures of acupuncture points and meridi- Casez R. Paris: nese Acupuncture. Is acupuncture effective for the treatment of chronic (Engl) 153: 532–535. 31. Hibbeler RC. NIH Consens Statement 15: 1–34.). 1995. 17. BMJ 321: 11. 27a. 1985. Acupuncture: does it burgh: Churchill Livingstone. Anatomical features contributing to the formation of 33. JAMA 283: 118–119. Human Anatomy Depart- 14. relates of acupuncture points. 39. Edinburgh: Surg 125: 567–572. Acupunct Electrother Res 9: 79–106. Gunn CC and Milbrandt WE. 42. [Transl. Lao L. Laage S. Kimura M. 1. tic acupuncture: concepts and methods. MA: Paradigm. New York: John Wiley and Sons. NJ: Prentice-Hall. Altern Ther Health Med 4: 23. A acupuncture points. 8. 32. Traditional Chinese Acupuncture Volume 1: Me- 24. 1994. 1995. Electromyographic activ- 13. 37. Statistics for Experi- tence of electrically located acupuncture points. Vincent CA and Lewith G. PA: Saunders. Mechanical 44. Acupuncture Textbook and Atlas.). 21. Shen J. 47. Chinese Acupuncture (English ed. chinois. Berman B. 1998. [Transl. Acupuncture. employing needling manipulation. and channel network. Beijing. Les characteristiques morphologiques des points 10. Langevin HM. Robbins Pathologic 533–535. Acupuncture techniques and devices. and Cipolla MJ. 11. 1975. and Skrzypulec V. Denmei S. On the evaluation of the therapeu- tic effect of acupuncture. if so. Gunn CC. Berkeley. fibroblasts and endothelial cells in tissue culture: a quantitative 43. Helms JM. icine. Chinese Acupuncture and Moxibustion. White AR and Ernst E. Trans Biomed Eng 20: 364–366.jap. Cotran RS. 2. 1994. terization of human skin conductance at acupuncture points. 1979. Evaluation of acupuncture for pain control after oral 48. Stux G and Pomeranz B. An investigation of the exis- 5. and Kistler A. Senelar R. Rabischong P. The Advanced Theory of Statistics. pain? A systematic review. 6. J Altern Comple. and Knipschild P. Gorawski EC. Ezzo J. 1980. 1984. 1990. London: Charles Griffin. Lao L. Ellis A. The evaluation of therapeu- signaling through connective tissue: a mechanism for the ther. Comunetti A. Worsley JR. 34. Am J Acup 5: 115–120. and Robbins SL. Niboyet JEH. 1995. CA: Medical Acupuncture. Chin Med J Singh BB. 1990. and Hunter JS. Reishmanis M. Acupuncture and 1992. King MH. 2000. Shanghai College of Traditional Medicine. 1969. Chinese Medicine. 1973. 1975. Ter Riet G. by 12. 40. Walter JB and Israel MS. 1999. Engineering Mechanics—Statics and Dynamics. 1975. ical and immunohistochemical studies on the induction of ’qi’ Berlin: Springer-Verlag.