Você está na página 1de 8

J Appl Physiol

91: 2471–2478, 2001.

Biomechanical response to acupuncture
needling in humans

HELENE M. LANGEVIN,1 DAVID L. CHURCHILL,1 JAMES R. FOX,2 GARY J. BADGER,3
BRIAN S. GARRA,4 AND MARTIN H. KRAG2
1
Departments of Neurology, 2Orthopaedics and Rehabilitation, 3Medical Biostatistics, and
4
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

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

Fig. 47) and averaging the suggested ically isolated from the skin-contacting foot. Just enough force is applied acupuncture points from seven different acupuncture text. 2). Applying too much pres- subjects (8 men and 8 women). The investigator holds the instrument after a 10-s delay. however. All needling procedures (insertion. and therefore upper and lower limits of the listed ranges for each point. 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. 39. with the instrument in its final orientation compensates for both of which are controlled by the computer. we found that the investigator could easily Acupuncture Needling maintain skin contact without causing visible skin compres- sion throughout a pullout test. The icant compared with typical pullout force. the needle is robotically advanced into the tissue tissue on the needle. rotated to perform manipulation (if called for). and custom-written control and data acquisition software. pulled out of the tissue. Under the computer’s strain-gauge loadcell measures all axial forces exerted by the control.org . motion (needle insertion and pullout). significant tissue compression artifact was found. following manner. the loadcell reading is tared. needling procedure is initiated. cutaway view with needle retracted. This is necessary eliminated many potential sources of investigator bias. and. 6. nipulation. In at each acupuncture point in all subjects. ma. To perform a pullout test. through a hole in the instrument’s skin-contacting foot (Fig. A: design schematic of acupuncture needling instrument. pullout. to maintain light contact with the skin. From left to right: cutaway view with needle extended. can compress the underlying tissue and could using the above formula fell within the recommended ranges potentially influence how the tissue responds to needling. J Appl Physiol • VOL 91 • DECEMBER 2001 • www. This ensured consistent experimental conditions and initiated.jap. 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. 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. BIOMECHANICAL RESPONSE TO ACUPUNCTURE NEEDLING 2473 the acupuncture point. grip (which are mounted to the loadcell’s live side) is signif- a personal computer fitted with a servomotor controller. side view. The second motor Once the instrument has been positioned and the loadcell generates needle rotation (manipulation). Inset shows needle in extended position. evaluation tests. B: needling instrument in use. needle depth determination sure. the system operates in the 2. Taring the system needling instrument contains two miniature servomotors. 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. 12. The loadcell is phys- books (1. 2. A 500-g capacity tared. and within this range no Needling system. This because the weight of the needle rotation motor and needle system consists of a hand-held needling instrument (Fig. inset). 33. 3.

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

0 g at control points.1 ⫾ 10.50 mm.1 g.19) ⫽ 26.7 ⫾ control points and acupuncture points (C). BI: 22.039]. control point: 87. Pullout force measurements. and the latter was significantly greater than that for NO (36.73.001.org . P ⬍ 0. P ⬍ 0. LI11. P ⬍ 0. a biomechanical aspect J Appl Physiol • VOL 91 • DECEMBER 2001 • www. Means and SD for age and BMI of participants that completed the study were 37.5 ⫾ 0.2 ⫾ 0. F(1.57) ⫽ 0.5 ⫾ 2.41 mm.. F(1.7 ⫾ 1. F(1.3 ⫾ 8.57) ⫽ 1.4. There was no significant difference in mean needle- Although the testing of individual acupuncture/con. a greater types [NO: 21. Mean pullout force (⫾SE) for UNI (97. with three (Ht2. Error 0.2 ⫾ 7.0.05).0. points than at control points in seven out of the eight DISCUSSION locations tested (Ht2. P ⫽ 0. Means are significantly (P ⬍ sons indicated that each manipulation type was signif.007] and UNI [acupuncture point: 109. and B57). the primary outcome measure. Fig.8. 0. Sp6. Our measurements of pullout force are the first tical significance (P ⬍ 0.001 for control points].001 for acupuncture points and F(2. completed the testing protocol.57) ⫽ 62. P ⫽ 0. 4C). The remaining 60.7 g). 4. insertion depth across the three needle-manipulation trol locations was not the aim of our study. respectively. differences in pullout force between acu- puncture and control points not were dependent on the type of needle manipulation.19) ⫽ 9. Secondary analyses were performed comparing pull- out force within needle-manipulation types and within point types (acupuncture vs.e. Mean pullout force at acupuncture points was 63. LI11.4 g. Fig.8 ⫾ 2. and UNI (C).07.35]. 4A].001]. P ⬍ acupuncture points and control points (B). BI [acupuncture point: 60.9.jap. control point: 34. Means are significantly 0.9 ⫾ 0. BIOMECHANICAL RESPONSE TO ACUPUNCTURE NEEDLING 2475 RESULTS Study Participants Sixty-one volunteers were enrolled in the study. There was no evidence that differences between nee- dle-manipulation types were dependent on point type (i. significant differences were found among the manipulation types [F(2.57) ⫽ 49. is graphically displayed in Fig. 1. Conversely. control) [F(2. Fig.37 mm. P ⬍ BI. quantification of needle grasp.57) ⫽ 18.8 g) (Fishers LSD.48 for needle manipulation by point-type interaction]. Height of bars represents geometric means.5 ⫾ 2.9 ⫾ 2. P ⫽ 0. control.05).2 g. point: 51. Fig.5 g) was significantly greater than that for BI (55. 4B]. F(2.5.5 ⫾ 5. P ⬍ 0.05). St36.001) different between needle-manipulation types (A) and between icantly different from the others (Fishers LSD. 4. LI4. acupuncture vs. Significant differences in pullout force were observed across the three needle- manipulation types [F(2. Lu6. Pairwise compari. Acupuncture and control points also differed different across the three needle-manipulation types within both significantly within NO [acupuncture point: 38.0 g. Means are also signifi- cantly different between acupuncture and control points with NO.3 g.57) ⫽ 75.2 yr and 26. Mean pullout force was also significantly greater at acupuncture points than at corresponding control points [F(1. One female participant withdrew during testing because of discomfort associated with the testing procedure.3 g compared with 53. There were no significant differences with respect to these subject characteristics between the groups of subjects randomized to the three needle-manipulation types.001. P ⫽ 0. Within acupuncture and control points. and Sp6) achieving statis.6 ⫾ 0. P ⬍ 0.5 ⫾ 5. control bars represent SE.4 g.7 ⫾ 1.19) ⫽ 4. UNI: average pullout force was observed at acupuncture 22. consisting of 38 women and 22 men.3 kg/m2.5. Pullout-Force Measurements Pullout force.

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

Hamill is also lar bundles (4. 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. 36). 47). 25. Yandow for assistance in conducting the study physiological properties of acupuncture points and and preparing the manuscript. manual acu- vs. first step toward determining the biological and clin- ture points and nonacupuncture points. the therapeutic effects lasting days to weeks and even same amount of needle grasp may have more power- permanently. 35) have been reported at This study was funded by the National Institutes of Health (NIH) Center for Complementary and Alternative Medicine Grant no. Gale A. nonacupuncture points. those points. This is con- potheses objectively but might. 30. a grasp has been described in acupuncture textbooks credible sham procedure but did not aim to test for for over 2. a wide variety of nee- effect. resulting in deformation of some studies (8. NIH Center for Research Resources Grant M01RR-00109. 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. 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. unteers. Apparent therapeutic effects acupuncture needle manipulation and biomechanical observed at control points were attributed to the “non.Weld for recruitment of vol- meridians so far have been mostly unconvincing. 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. other hand. This study constitutes a differences in therapeutic response between acupunc. sistent with available evidence from clinical trials. Reviews of these studies concluded that. also provide important biological markers that can lation at nonacupuncture points (24. In addition. secretion of paracrine or autocrine factors. 39. 29). since neurovascular bun- plexing claim that acupuncture treatments can have dles are located along connective tissue planes. Recent well.org . 32) and various types of nerve gratefully acknowledged. In the clinical situation.jap. with illustrations. In the shorter term. 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. Some differences nevertheless necessarily ex- needle manipulation appears to have pronounced ef. However. R. (between muscles or between muscle and bone or stream effects ranging from cell contraction. Needle grasp may therefore be pression. BIOMECHANICAL RESPONSE TO ACUPUNCTURE NEEDLING 2477 become mechanically coupled to the tissue. potentially associated with long-lasting cellular and eralized effect of noxious stimulation (“diffuse noxious extracellular effects. tendon) (6. Winding underlying condition. 14. with a mechanism involving tissue winding. These clinical be used in clinical trials of acupuncture. stimulation of these structures by the mechanical ulation on pullout force dominates over the effect of matrix deformation caused by tissue winding. nonacupuncture The use of a computer-controlled instrument to per- point). appears to be more subtle. Needle trials showed the effectiveness of acupuncture vs. and Adam D. 31) but not in others (28. events in the tissue. gene ex. the impact of the insertion and manipulation of needles. needle placement (acupuncture vs. These biomechanical events are specific physiological effect of needling. and acupuncturists The difference between these two levels of effects fits modify these techniques according to the patient’s age. This needling acupuncture points and that of nonneedle study for the first time demonstrates a link between placebos (2. 33). A remove an important therapeutic component. Developing an understanding inhibitory controls or DNIC”) (42. ical significance of this phenomenon. On the extracellular connective tissue matrix. 43). 11. 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). ist between our study protocol and clinical acupunc- fects no matter where the needle is placed. 26. endings (7.000 years (27a). 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. 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. Attempts to identify unique anatomical and/or We thank Jason A. The ongoing support of Dr. palpation of tissues. although many of these trials were puncture would be valuable in future studies. connective tissue can wind around the needle at These effects may be prolonged and explain the per. and sensa- of connective tissue in response to needle rotation tions obtained during the needling itself (6. Riesner and Richard A. poorly controlled. allowing controlled a technique (needle manipulation) vs. slightly greater at acupuncture points because more and neuromodulation of afferent sensory input (21). Substrate ture. ful downstream effects at acupuncture points via Our results indicate that the effect of needle manip. in a clinical setting. these same effects may needling or minimal needle insertion without manipu. Doran for assistance Various histological structures such as neurovascu. acupuncture points. 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. dling techniques are used (22). W. on the other hand. 44). This matrix de. J Appl Physiol • VOL 91 • DECEMBER 2001 • www. 42. The technique of practice.” or to the gen.

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