Neuroscience, Neurophysiology and Acupuncture
Karavis Miltiades M.D.,Dip.Ac.
Table 1 has unfortunately been lost.
ABSTRACT
Neuroscience provides an understanding of the organization and physiology of the nervous system. This understanding is based on an appreciation of the structure of the nervous system and on the relationship between his structure and function. The human nervous system is extraordinarilly complex.The brain is composed of about 1012 cells (neurones). These cells uniquelly possess specialized processes for receiving (dedrites) and transmitting (axons) information. These stimulus - response systems permit our body to be in contact with environmental fluctuations. There are several thousand types of nerves, neurotransmitters, receptors and chemical mediators that compose this fundamental system. Acupuncture, as needling therapy, is a kind of specialized sensory stimulation that is analysed through sensory neural pathways .
To understand, therefore, the action of Acupuncture we have to analyse the Anatomy, physiology and physiolopathology of Nervous System. In this effort we'll be helped by the knowledge of contemporary neuroendocrinology and chemoarchitecture of the brain. Many neural theories are developed to explain the mechanisms of action of Acupuncture. It is now quite clear that Acupuncture reacts in local, regional (spinal cord) and general (brain) levels. Therefore, placing one or more needles on a particular point (or area) of the body activates neural pathways on three different levels provoking local, regional, and general reactions: a)The local reaction is a multifactorial phenomenon. The electric injury potential due to the needle, the presful and synthesis of opioid peptides at the place of the injury, the substance P, histamine like substances bradikinine, serotonin, proteolitic enzymes all around the needle, occured during every needling therapy. b)The regional reaction concerns the activation of an largest area (2-3 dermotomes) through reflex arches. We can analyse the viscero-cutaneous, cutaneo-visceral, cutaneo-muscular and viscero-muscular reflexes and also the vegetative, stretch and polisynaptic segmental reflexes. c)The general reaction mainly activates the brain central mechanism of internal homeostasis. Discussing the role of central neurotransmiters we can explain the action of Acupuncture in acute and chronic pain syndromes, in addictions, in psychiatric diseases. More precisely, we shall talk about the modulatory systems that are activated through Acu points: a) opioid systems, b) non opioid systems and c) central sympathetic inhibitory mechanisms.
INTRODUCTION
The application of a needle (superficially to the skin or deep into muscular or nervous tissues, ligaments or bones) is a sensory stimulation. The purpose of therapy seems to be the selective stimulation of skin points or areas of our body. Stimulation takes place at several points at the same time. It is believed that every combination of points activates different circuits and it is clear that the character of the stimulus is of primary importance for the therapeutic result.
By character of stimulation (or parameter of stimulation) we mean:
a) The depth of stimulation (skin, muscles, periosteum, ganglia)
b) The intensity of stimulation (DE CHI, electro-acupuncture, Laser)
c) The area of stimulation (acu-point, dermotome, myotome)
d) The combination of stimulation points.
In the table 1 we can see the importance of stimulation parameters and the possibilities offered by this knowledge for the systematisation of our practice.
It is well known that the nervous system with its sensory peripheral receptors, afferent sensory pathways, central cerebral nuclei, efferent pathways and effector peripheral organs directs the mechanisms of action and reaction of the body when an external or internal stimulus influences it. The various changes in the external or internal environment are handled in this manner. In the case of acupuncture, the stimulus is external (needle) and activates mostly homoeostatic mechanisms. Stimulation may be effected by simple needle (puncture - dry needling), subcutaneous infusion of pharmaceutical substances (mechanical and chemical stimulation - wet needling) or electrical stimulation (sensory block) and concerns mainly the epidermis, dermis and muscle tissue.
According to Pomeranz[1] an injury to the skin activates the sensory receptors of small afferent nerve fibres of Aä and C axon size (Nerve fibres are classified by size and according to whether they originate in skin or muscle: large diameter myelinated nerves Ab (skin) or type I (muscle) carry «touch» and propioception, respectively. Small diameter myelinated Ad (skin) or types II and III (muscle) carry «pain». The smallest unmyelinated C (skin) and type IV (muscle) also carry «pain». Types II, III, IV and C also carry non-painful messages).
SENSORY DISTRIBUTION - MACKENZIE'S THEORY
The skin, the muscles, the ligaments, the joints, the bones, the viscera and also the vessels related to them are functionally controlled by defined segments of the spinal cord called neurotomes. Sensory afferent fibres flock towards the neurotomes coming from the dermatomes, myotomes, viscerotomes and sclerotomes according to their somotomic origin, that is to say, according to the embryonic somotomium they come from. The formation of these primitive segments or somites reflects the metamerism.
The structure of the nervous system is such that a skin area, a muscle, a group of ligaments, a viscera, the segment of a bone, are served by one and the same centre called myelotome (Mackenzie's theory, visceral-somatic convergence theory and peripheral nerve-branching theory) [2,3,4,5]. In the course of embryonic life, innervation of the bones, of the muscles of the skin and of the viscera is symmetrical. But as the organism grows it loses its initial symmetry. Finally, only the intercostal nerves preserve the initial symmetrical correspondence between neurotomes, dermatomes, myotomes and sclerotomes. The knowledge of the topographic anatomic structure of these zones, is indispensable to the acupuncturer and it possesses a particular clinical value for the localisation of diseases of the posterior or anterior roots of the spinal nerves and also for the right choice of the acupuncture points (or areas) which have to be stimulated.
Thus, according to Mackenzie's theory the sensory cutaneous stimulation (e.g. placement of a needle) will cause functional reflex reactions to the muscles, the muscle vessels and the ligaments that receive sensory or motor innervation from the same myelotome. The reflex muscle contraction, the hyperalgesia, the tenderness and the associated autonomic manifestation (sympathetic and parasympathetic hyperactivity) are localized not to the site of the injury but to an area at a distance and may involve only a small part of a dermatome. The presence of cutaneous hyperalgesia associated with deep somatic or visceral pain disorders had been recognized by many physiologists like Head, Sherrington, Ross, Sturge and others. We believe that acupuncture acts at a spinal or supraspinal level, using similar neural pathways that produse referred pain (antodromic activation of receptors at a distance). Also, according to "referred" visceral pain mechanism and to projection-convergence theory os Rusck, our skin, using his own "language" (painfull skin or muscle areas in visceral pain diseases of the heart, gallblader, stomac etc) will show to us the exactly skin area that we must stimulate to eliminate the vicious cycle of pain.[2]
I shall mention as an example the placement of a needle (wet needling) at the acupuncture point Stomach 36 at a depth of 3 cm. This point is in the lower limbs, 1 cm outside the front margin of the leg and 3 cm below the tibial convexity (motor point of the anterior tibial muscle). This stimulation will cause:
a) Local sensory stimulation of the area of the leg that is sensorially innervated by the cutaneous branch of the major saphene nerve (neurotome L3-L4).
b) Stimulation of sensory receptors and mechano-receptors of the anterior tibial muscle (motor innervation by the deep radial nerve, L4, L5, S1 neurotome).
c) Vasoconstriction or vasodilatation (depending on the stimulation parameters) of the front tibial artery, that undertakes the cutaneous and muscular arterial irrigation of the area.
d) Myochalasis, that will influence all groups of muscles that have a common neurotomal distribution in the L5 myelotome and in particular on the long extensor of the big toe (L4, L5, S1), the long and short tibial muscle (L4, L5) and the major gluteal muscle (L5, S1, S2) and finally
e) Activation of serotoninergic and endorphinergic pain modulation systems (central action).
For all these reasons, this point is selected for stimulation in all cases of back pain or sciatica with L4-S1 pain distribution, with or without neurological findings.
Stux and Pomeranz,[6] formulated the hypothesis that three centres are activated by acupuncture to release chemical transmitters that block pain messages.
a) The spinal cord that uses enkephalin and dynorphin (low frequency) and perhaps GABA (high frequency)
b) The midbrain uses enkephalin to activate the raphe descending system which inhibits spinal cord pain transmission by a synergic effect of the monoamines, serotonin and norepinephrine.
c) The hypothalamus-pituitary uses endorphin.
Johannes Bischko,[7] analysing the control loop theory (feedback mechanism) states that every acupuncture point displays at least 4 criteria:
1. Local action
2. Regional action
3. An action extending beyond a certain region and
4. General action.
Watkins and Mayer [8,9] in a paper published in Science have proposed the possible activation with acupuncture (and other physical agens) of six different endogenous analgesic systems: neural opiate, hormonal opiate, neural non opiate, hormonal non opiate, unknown opiate and unknown non-opiate systems.
We could say that by placing a needle on a particular point (or area) of the body, nervous pathways are activated on three different levels provoking a) Local reactions concerning an small area of 1-3cm, b) regional (segmental) reactions concerning an area of 1-3 dermotomes and c) general reactions concerning a massive response from the Central Nervous System. We will analyse the action of acupuncture at these three levels: periphery, spinal cord and central nervous system.
LOCAL ACTION OF ACUPUNCTURE STIMULATION
This action of acupuncture is localised in a small skin area, is due in principal to the tissue lesion caused by placing the needle on the skin and concerns all acupuncture points without exception (non-specific action of acu-points).
Deactivation of superficial painful skin points.
The local reaction is the result of many factors. Initially, the difference in electric potential existing between the needle and the layers of the skin where it is placed, the difference in temperature between the needle and the skin and the quality of the needle, creates a galvanic current of low intensity. That means that the needle is a source of microenergy.[10,11]
This electric current is capable of stimulating the cell membrane, of increasing its permeability and finally of transforming the accumulation of Na and K ions in the two poles of the membrane (intra and extracellular) leading the cells, the adjacent sensory receptors and the free nervous endings to a state of excitability.
Moreover, cell injuries of the skin (an in particular of the mast cells of the Lewis layer) provoke a secretion of bradykinin, serotonin and proteolytic enzymes, ACTH and also of histamine-like substances all around the needle.[12]
Yaksh and Hammond [13] point out that three types of local substances participate in peripheral transduction of nociceptive stimuli into nociceptive impulses (pain).
1) Those that activate nociceptive afferent fibres and produce pain (bradykinin, acetylcholine and potassium).
2) Those that facilitate the pain evoked by chemical and physical stimuli by sensitisation of nociceptors but are ineffective in evoking pain themselves (prostaglandins) and
3) those that produce extravasation, such as substance P. Substance P (and perhaps other peptides) may have a role in influencing the milieu of the peripheral afferent terminals, and thus in the transduction of nociceptive information. Substance P, like other peptides, is synthesised in the cell bodies of small cells (type B cells) of spinal ganglia and the gasserian ganglion by the ribosomal synthesis of large precursor prehormones. [14] If the stimulation of acupuncture is a kind of nociceptive stimulation, we can hypothesise the presence of this substances at the site of the needle.
Therefore, it can be said that the main neurotransmitter of pain to the periphery is substance P. Substance P is a peptide transported by the neural fibres till the last nerve terminals of the neural C-fibres. About 20% of the cell body in the spinal dorsal root ganglia contain substance P. These cells have small somas and small unmyelinated and finely myelinated axons. Their peripheral processes have been found in the epidermis and in the walls of blood vessels and glands. Their central processes project to the superficial layers of the dorsal horns of the spinal cord. Also, opioid receptors are present on primary afferent neurons (thinly myelinated and unmyelinated cutaneous nerves), on sympathetic postganglionic neurons. Now there are many findings that indicate the presence and synthesis of opioid peptides in different types of inflammatory cells at the site of tissue injury. Because the local reaction is a kind of small inflammatory reaction, the peripheral antinociceptive effect of exogenous or endogenous opioids will be enhanced especially 3-4 days after the acupuncture treatment. Substance P, together with the above mentioned substances provokes local clinical phenomena of inflammation such as swellings, red spots, itching or burning pain.
After withdrawing the needle, the unequal distribution of electrical potential (because of the high concentration of K ions) round the edges of the injury creates an electric «flux potential field» which acts as stimulator of the free nerve endings of the skin for 72 hours after the application of acupuncture. The nature of the stimulation varies according to the needle, the depth of the injury, the quality of the tissues and the readiness of the nervous system of the patient.
Inactivation of the deep painful muscle points
The quality of the stimulus depends primarily on the depth of entry of the needle and the quality of the tissue in which it is placed (target-tissue). Often, the needle is placed in muscular tissue to specific points that are painful to pressure called trigger points [15] or in specific muscle points called motor points (erb points).
Trigger points are painful points in muscular tissue and are detected in many degenerative disorders of the spinal cord, in all cases of musculoskeletal pain of radiculopathic origin (neuropathic pain) and in local muscle, ligament or joint injuries (especially overuse syndromes). About 70% of all acu points coincide with trigger points. Meltzack, Stillwell and Fox [16]demostrated «a remarkably high degree (71%) of correspondence between trigger points and acupoints». Liao has also reported that many acupoints coincide with the motor points (Erb points) of skeletal muscle.
The simple placement of the needle at these points achieves: a) the inactivation of the trigger point (reduction of the intensity and discharge rate of pain sensory stimuly from the muscle to the higher sensory centres) and b) the activation of spinal reflexes. The receptor organs of the muscular shaft (propioceptive sense) and the cells of the anterior horns of the spinal cord participate in this process. This mechanism will be analysed in detail in the discussion about the regional action of acupuncture.
ABSTRACT
Neuroscience provides an understanding of the organization and physiology of the nervous system. This understanding is based on an appreciation of the structure of the nervous system and on the relationship between his structure and function. The human nervous system is extraordinarilly complex.The brain is composed of about 1012 cells (neurones). These cells uniquelly possess specialized processes for receiving (dedrites) and transmitting (axons) information. These stimulus - response systems permit our body to be in contact with environmental fluctuations. There are several thousand types of nerves, neurotransmitters, receptors and chemical mediators that compose this fundamental system. Acupuncture, as needling therapy, is a kind of specialized sensory stimulation that is analysed through sensory neural pathways .
To understand, therefore, the action of Acupuncture we have to analyse the Anatomy, physiology and physiolopathology of Nervous System. In this effort we'll be helped by the knowledge of contemporary neuroendocrinology and chemoarchitecture of the brain. Many neural theories are developed to explain the mechanisms of action of Acupuncture. It is now quite clear that Acupuncture reacts in local, regional (spinal cord) and general (brain) levels. Therefore, placing one or more needles on a particular point (or area) of the body activates neural pathways on three different levels provoking local, regional, and general reactions: a)The local reaction is a multifactorial phenomenon. The electric injury potential due to the needle, the presful and synthesis of opioid peptides at the place of the injury, the substance P, histamine like substances bradikinine, serotonin, proteolitic enzymes all around the needle, occured during every needling therapy. b)The regional reaction concerns the activation of an largest area (2-3 dermotomes) through reflex arches. We can analyse the viscero-cutaneous, cutaneo-visceral, cutaneo-muscular and viscero-muscular reflexes and also the vegetative, stretch and polisynaptic segmental reflexes. c)The general reaction mainly activates the brain central mechanism of internal homeostasis. Discussing the role of central neurotransmiters we can explain the action of Acupuncture in acute and chronic pain syndromes, in addictions, in psychiatric diseases. More precisely, we shall talk about the modulatory systems that are activated through Acu points: a) opioid systems, b) non opioid systems and c) central sympathetic inhibitory mechanisms.
INTRODUCTION
The application of a needle (superficially to the skin or deep into muscular or nervous tissues, ligaments or bones) is a sensory stimulation. The purpose of therapy seems to be the selective stimulation of skin points or areas of our body. Stimulation takes place at several points at the same time. It is believed that every combination of points activates different circuits and it is clear that the character of the stimulus is of primary importance for the therapeutic result.
By character of stimulation (or parameter of stimulation) we mean:
a) The depth of stimulation (skin, muscles, periosteum, ganglia)
b) The intensity of stimulation (DE CHI, electro-acupuncture, Laser)
c) The area of stimulation (acu-point, dermotome, myotome)
d) The combination of stimulation points.
In the table 1 we can see the importance of stimulation parameters and the possibilities offered by this knowledge for the systematisation of our practice.
It is well known that the nervous system with its sensory peripheral receptors, afferent sensory pathways, central cerebral nuclei, efferent pathways and effector peripheral organs directs the mechanisms of action and reaction of the body when an external or internal stimulus influences it. The various changes in the external or internal environment are handled in this manner. In the case of acupuncture, the stimulus is external (needle) and activates mostly homoeostatic mechanisms. Stimulation may be effected by simple needle (puncture - dry needling), subcutaneous infusion of pharmaceutical substances (mechanical and chemical stimulation - wet needling) or electrical stimulation (sensory block) and concerns mainly the epidermis, dermis and muscle tissue.
According to Pomeranz[1] an injury to the skin activates the sensory receptors of small afferent nerve fibres of Aä and C axon size (Nerve fibres are classified by size and according to whether they originate in skin or muscle: large diameter myelinated nerves Ab (skin) or type I (muscle) carry «touch» and propioception, respectively. Small diameter myelinated Ad (skin) or types II and III (muscle) carry «pain». The smallest unmyelinated C (skin) and type IV (muscle) also carry «pain». Types II, III, IV and C also carry non-painful messages).
SENSORY DISTRIBUTION - MACKENZIE'S THEORY
The skin, the muscles, the ligaments, the joints, the bones, the viscera and also the vessels related to them are functionally controlled by defined segments of the spinal cord called neurotomes. Sensory afferent fibres flock towards the neurotomes coming from the dermatomes, myotomes, viscerotomes and sclerotomes according to their somotomic origin, that is to say, according to the embryonic somotomium they come from. The formation of these primitive segments or somites reflects the metamerism.
The structure of the nervous system is such that a skin area, a muscle, a group of ligaments, a viscera, the segment of a bone, are served by one and the same centre called myelotome (Mackenzie's theory, visceral-somatic convergence theory and peripheral nerve-branching theory) [2,3,4,5]. In the course of embryonic life, innervation of the bones, of the muscles of the skin and of the viscera is symmetrical. But as the organism grows it loses its initial symmetry. Finally, only the intercostal nerves preserve the initial symmetrical correspondence between neurotomes, dermatomes, myotomes and sclerotomes. The knowledge of the topographic anatomic structure of these zones, is indispensable to the acupuncturer and it possesses a particular clinical value for the localisation of diseases of the posterior or anterior roots of the spinal nerves and also for the right choice of the acupuncture points (or areas) which have to be stimulated.
Thus, according to Mackenzie's theory the sensory cutaneous stimulation (e.g. placement of a needle) will cause functional reflex reactions to the muscles, the muscle vessels and the ligaments that receive sensory or motor innervation from the same myelotome. The reflex muscle contraction, the hyperalgesia, the tenderness and the associated autonomic manifestation (sympathetic and parasympathetic hyperactivity) are localized not to the site of the injury but to an area at a distance and may involve only a small part of a dermatome. The presence of cutaneous hyperalgesia associated with deep somatic or visceral pain disorders had been recognized by many physiologists like Head, Sherrington, Ross, Sturge and others. We believe that acupuncture acts at a spinal or supraspinal level, using similar neural pathways that produse referred pain (antodromic activation of receptors at a distance). Also, according to "referred" visceral pain mechanism and to projection-convergence theory os Rusck, our skin, using his own "language" (painfull skin or muscle areas in visceral pain diseases of the heart, gallblader, stomac etc) will show to us the exactly skin area that we must stimulate to eliminate the vicious cycle of pain.[2]
I shall mention as an example the placement of a needle (wet needling) at the acupuncture point Stomach 36 at a depth of 3 cm. This point is in the lower limbs, 1 cm outside the front margin of the leg and 3 cm below the tibial convexity (motor point of the anterior tibial muscle). This stimulation will cause:
a) Local sensory stimulation of the area of the leg that is sensorially innervated by the cutaneous branch of the major saphene nerve (neurotome L3-L4).
b) Stimulation of sensory receptors and mechano-receptors of the anterior tibial muscle (motor innervation by the deep radial nerve, L4, L5, S1 neurotome).
c) Vasoconstriction or vasodilatation (depending on the stimulation parameters) of the front tibial artery, that undertakes the cutaneous and muscular arterial irrigation of the area.
d) Myochalasis, that will influence all groups of muscles that have a common neurotomal distribution in the L5 myelotome and in particular on the long extensor of the big toe (L4, L5, S1), the long and short tibial muscle (L4, L5) and the major gluteal muscle (L5, S1, S2) and finally
e) Activation of serotoninergic and endorphinergic pain modulation systems (central action).
For all these reasons, this point is selected for stimulation in all cases of back pain or sciatica with L4-S1 pain distribution, with or without neurological findings.
Stux and Pomeranz,[6] formulated the hypothesis that three centres are activated by acupuncture to release chemical transmitters that block pain messages.
a) The spinal cord that uses enkephalin and dynorphin (low frequency) and perhaps GABA (high frequency)
b) The midbrain uses enkephalin to activate the raphe descending system which inhibits spinal cord pain transmission by a synergic effect of the monoamines, serotonin and norepinephrine.
c) The hypothalamus-pituitary uses endorphin.
Johannes Bischko,[7] analysing the control loop theory (feedback mechanism) states that every acupuncture point displays at least 4 criteria:
1. Local action
2. Regional action
3. An action extending beyond a certain region and
4. General action.
Watkins and Mayer [8,9] in a paper published in Science have proposed the possible activation with acupuncture (and other physical agens) of six different endogenous analgesic systems: neural opiate, hormonal opiate, neural non opiate, hormonal non opiate, unknown opiate and unknown non-opiate systems.
We could say that by placing a needle on a particular point (or area) of the body, nervous pathways are activated on three different levels provoking a) Local reactions concerning an small area of 1-3cm, b) regional (segmental) reactions concerning an area of 1-3 dermotomes and c) general reactions concerning a massive response from the Central Nervous System. We will analyse the action of acupuncture at these three levels: periphery, spinal cord and central nervous system.
LOCAL ACTION OF ACUPUNCTURE STIMULATION
This action of acupuncture is localised in a small skin area, is due in principal to the tissue lesion caused by placing the needle on the skin and concerns all acupuncture points without exception (non-specific action of acu-points).
Deactivation of superficial painful skin points.
The local reaction is the result of many factors. Initially, the difference in electric potential existing between the needle and the layers of the skin where it is placed, the difference in temperature between the needle and the skin and the quality of the needle, creates a galvanic current of low intensity. That means that the needle is a source of microenergy.[10,11]
This electric current is capable of stimulating the cell membrane, of increasing its permeability and finally of transforming the accumulation of Na and K ions in the two poles of the membrane (intra and extracellular) leading the cells, the adjacent sensory receptors and the free nervous endings to a state of excitability.
Moreover, cell injuries of the skin (an in particular of the mast cells of the Lewis layer) provoke a secretion of bradykinin, serotonin and proteolytic enzymes, ACTH and also of histamine-like substances all around the needle.[12]
Yaksh and Hammond [13] point out that three types of local substances participate in peripheral transduction of nociceptive stimuli into nociceptive impulses (pain).
1) Those that activate nociceptive afferent fibres and produce pain (bradykinin, acetylcholine and potassium).
2) Those that facilitate the pain evoked by chemical and physical stimuli by sensitisation of nociceptors but are ineffective in evoking pain themselves (prostaglandins) and
3) those that produce extravasation, such as substance P. Substance P (and perhaps other peptides) may have a role in influencing the milieu of the peripheral afferent terminals, and thus in the transduction of nociceptive information. Substance P, like other peptides, is synthesised in the cell bodies of small cells (type B cells) of spinal ganglia and the gasserian ganglion by the ribosomal synthesis of large precursor prehormones. [14] If the stimulation of acupuncture is a kind of nociceptive stimulation, we can hypothesise the presence of this substances at the site of the needle.
Therefore, it can be said that the main neurotransmitter of pain to the periphery is substance P. Substance P is a peptide transported by the neural fibres till the last nerve terminals of the neural C-fibres. About 20% of the cell body in the spinal dorsal root ganglia contain substance P. These cells have small somas and small unmyelinated and finely myelinated axons. Their peripheral processes have been found in the epidermis and in the walls of blood vessels and glands. Their central processes project to the superficial layers of the dorsal horns of the spinal cord. Also, opioid receptors are present on primary afferent neurons (thinly myelinated and unmyelinated cutaneous nerves), on sympathetic postganglionic neurons. Now there are many findings that indicate the presence and synthesis of opioid peptides in different types of inflammatory cells at the site of tissue injury. Because the local reaction is a kind of small inflammatory reaction, the peripheral antinociceptive effect of exogenous or endogenous opioids will be enhanced especially 3-4 days after the acupuncture treatment. Substance P, together with the above mentioned substances provokes local clinical phenomena of inflammation such as swellings, red spots, itching or burning pain.
After withdrawing the needle, the unequal distribution of electrical potential (because of the high concentration of K ions) round the edges of the injury creates an electric «flux potential field» which acts as stimulator of the free nerve endings of the skin for 72 hours after the application of acupuncture. The nature of the stimulation varies according to the needle, the depth of the injury, the quality of the tissues and the readiness of the nervous system of the patient.
Inactivation of the deep painful muscle points
The quality of the stimulus depends primarily on the depth of entry of the needle and the quality of the tissue in which it is placed (target-tissue). Often, the needle is placed in muscular tissue to specific points that are painful to pressure called trigger points [15] or in specific muscle points called motor points (erb points).
Trigger points are painful points in muscular tissue and are detected in many degenerative disorders of the spinal cord, in all cases of musculoskeletal pain of radiculopathic origin (neuropathic pain) and in local muscle, ligament or joint injuries (especially overuse syndromes). About 70% of all acu points coincide with trigger points. Meltzack, Stillwell and Fox [16]demostrated «a remarkably high degree (71%) of correspondence between trigger points and acupoints». Liao has also reported that many acupoints coincide with the motor points (Erb points) of skeletal muscle.
The simple placement of the needle at these points achieves: a) the inactivation of the trigger point (reduction of the intensity and discharge rate of pain sensory stimuly from the muscle to the higher sensory centres) and b) the activation of spinal reflexes. The receptor organs of the muscular shaft (propioceptive sense) and the cells of the anterior horns of the spinal cord participate in this process. This mechanism will be analysed in detail in the discussion about the regional action of acupuncture.
REGIONAL ACTION OF ACUPUNCTURE STIMULATION
There are many findings that acupuncture act at a spinal (segmental or regional) level. Noxious stimuli from the periphery lead to release peptides in the spinal cord level. These peptides (tachykinins substance P, neurokinin A, calcitonine gene-related peptide, somatostatin etc) modulate the transmition of nociceptive information to the CNS. Using treatment modalities like TENS, Acupuncture and electroacupuncture, we can block the nonociceptive signals, activating descending pain inhibitory systems which act at the level of the specific myelotome. Acupuncture and electroacupuncture have an inhibitory effect on interneurons of the spinal cord (lamina V) and this inhibition is mediated by opiate pain-relieving system.[17] Also, many laboratories have shown changes in dorsal horn cell activity (gating) during mechanical, chemical and electrical stimulation of somatic and visceral fields. Transcutaneous electrical nerve stimulation (TENS) of somatic areas dicreases the spontaneous and noxiously evoked activity of a majority of dorsal horn neurons (wide-dynamic-range (WDR) cells, High threshold (HT) cells, and high threshold inhibitory (HTi) cells), reducing the perception of pain. [18]
This mechanism can be the spinal (regional) action of many analgesic physical methods which we use in daily practice in physiotherapy. Another regional reaction concerns the activation of an area through reflex arches. Those are produced after the stimulation of a peripheral sensory receptor. The stimulus is directed with afferent neural fibers to a sensory or motor nucleus of the spinal cord and a response reaction is produced there.
Analytically:
Viscero-cutaneous reflex or splanchno-fascial reflex. According to that, a functional or organic disease of a viscera causes pain, hypalgesia, tension or irritation to a particular area of the skin. As a general rule, the skin area where pain is projected has, in relation to the painful viscera, common somotomic origin as to the embryo and consequently it is innervated sensorially from the same neurotome of the spinal cord. The skin and the related viscera have the same segmental innervation usually by dorsal roots, spinal nerves and nuclei (referred pain resulting from reflex phenomena). The nociceptive impulses from the affected viscera pass to the dorsal horn and then to anterior horn of spinal cord across interneurons. Visceral afferent nociceptors converge on the same pain projection neurons as the afferents from the skin.[19,20,21,22]
For example, stimulation of the descending colon with barium chloride is going to create paleness (shrinking of the melanin cells-melanocytes) in an area or 2-3 neurotomes of the specific myelotomes (T9-T12). Moreover, injection of adrenaline 10% to the stomach gastric mucosa, in the gall bladder or in the fascia of the spleen, is going to create skin «shining» at a specific small area of the dermotomes of those organs. [23]
Pain in the gall bladder is projected on the skin of the right hypochondrium and on the top part of the right shoulder, a pain related to stomach ulcers corresponding to the 11th thoracic vertebra. The viscero cutaneous reflex we have just described is transmitted via the sympathetic chain. Dissection of the spinal cord does not affect this reflex. It is abolished by the dissection of the sympathetic chain. This reflex is a diagnostic reflex.
Cutaneous visceral reflex . The irritation of a skin point influences functionally the organ by which the cutaneous area is connected according to the neurotomes. Experimentally, to patients with acute angina pectoris the injection of procaine in cutaneous tender points of the anterior thoracic wall brings about fast recession of the precordial pain. Electrical stimulation of the point Futu (L.I. 18) on both sides, provokes analgesia capable of achieving thyroidectomy. This point is found in an area of innervation from the third dorsal cervical spinal nerve. The fascial of the thyroid gland and the above lying skin area where the specific acupuncture point is found are sensorially innervated from the same cervical myelotome. This reflex does not depend on superior brain centres. It follows a clearly neurotomic distribution. Dissection of the visceral nerves abolishes the reflex. Dissection of the vagus nerve does not influence the healing effect. It looks like the myotatic, monosynaptic reflexes. This is a therapeutic reflex.
Viscero-muscular and viscero-visceral or somato-autonomic reflexes are internal reflexes. It is they who interpret muscular contraction and vasocontraction observed in diseases of the internal organs. Sensory fibres from the muscles, the vessels and the affected organ originate from the same myelotome on neighbouring nuclei which are functionally interconnected.[24] This reflex produses reflex spasm of the skeletal muscle (trigger points of m. pectoralis) during myocardial ischemia. Also, through this reflex we interpret muscular pain during the function of the muscle under conditions of limited blood supply.[25] The sensation of needle insertion into somatic nerve endings in the muscle, ascends with afferent impulses to the anterior hypothalamus. Efferent impulses originate from the same reflex centre of hypothalamus, descend to the cholinergic vasodilator nerve and dilate the blood vessels of the muscle. Dissection of the dorsal spinal roots and that of the visceral nerves abolishes this reflex. A kind of viscero-visceral reflex is activated during the direct excitation of a ganglion by placing a needle deeply in the ganglion or all around the ganglion. As an example I would like to mention point SI 18, which is a meeting point of the head of the arm 3 Yang meridians. This point is being acupunctured during acute pain of the muscular - skeletal system. Why this point is so important in treatment of myoskeletal diseases. It is mentioned [26] that application of local anaesthetics to the mucosa overlying the sphenopalatine ganglion can block pain and is extremely effective on myoskeletal pain especially of the neck and back.
The acupuncture point LE 18 and the sphenopalatine ganglion coincide. In this area, there exists the largest collection of neurons in the head outside the brain itself. It is intimately connected to the trigeminal nerve and nucleus, and the superior cervical sympathetic ganglion. It seems to be the final switch between the body and the brain.
Somatomotors or cutaneo-muscular segmental reflexes. A harmful stimulus to the skin stimulates the axons of sensory fibres of groups III and IV of peripheral nerves. The information of stimulation enters the posterior horns of the spinal cord and is transmitted with the help of intermediate neurons to the motor neurons of the anterior horns. This pathway is polysynaptic and permits on one hand control and on the other deviation of sensory stimulation. Thus, the stimulation of a group of sensory receptors on the muscles, tendons or the skin will cause contraction or relaxation of muscles in the stimulated area (segmental distribution of the reflex). In this manner, by a sensory stimulus (puncture) it is possible to enlist neurons on the same or on the opposite side of the initial stimulation. The usual response to the sensory stimulus is the ipsilateral stimulation of flexors and the inhibition (relaxation) of extensors and the contralateral inhibition of flexors and stimulation of extensors (flexor and cross-extensor reflex).[27,28] Most rehabilitation treatments by electrophysical agens and, of course, acupuncture, use cutaneo-muscular reflexes to achieve muscle relaxation and to ameliorate the intramuscular blood supply to individual muscles or muscular groups. The selection of the area to be stimulated depends on the target muscle.
Vegetative reflexes are reflexes through the vegetative nervous system (sympathetic and parasympathetic). There is a large number of short and long vegetative reflexes which "close" the nervous circuit in the brain, the spinal cord, in the big nervous ganglia or in smaller peripheral ganglia. There are not only segmental reflexes. Many vegetative reflexes have been describe in medicine. As an example I will mention the segmental and suprasegmental reflexes that are prodused due to local biochemical changes and tissue damage in patiens with acute myocardial ischemia (AMI). This reflex is known as Bezold-Jarich reflex (abnormal vagovagal reflex) and produce severe bradycardia, peripheral vasodilation, severe hypotension and atrioventricular block. These reflexes involves afferents and efferents of both cardiac vagi and cardiac sympathetic nerves which produse sympathosympathetic reflexes. In the AMI patiens exist also suprasegmental reflex responses result from nociceptively induced stimulation of the medullary centers, hypothalamic centers, limbic structures and neuroendocrine function.[29]
According to Gunn, some other common condition of autonomic dysfunction that responce well to acupuncture treatment are the vasomotor, sudomotor, glandular hyperactivity and smooth muscle spasm observing in spondylotic radiculopathy. When pain dissapeare, this autonimic phenomena dissapeare.
Vegetative reflexes can be activated by a) local stimuli, b) general stimuli and c) regional stimuli. From the university of Goteborg [30] we have the information that acupuncture may affect the sympathetic system via mechanism at the hypothalamic and brainstem levels and the post-stimulatory sympathetic inhibition that creates, persist for more that 12 hours after acupuncture.
Vegetative reflexes are the clearest evidence of the organisms reaction as an open thermodynamic system. We know very little about these reflexes. The major problem is in describing the connections between the human cortex and the peripheral outflow to smooth muscles, cardiac muscles, secreting glands, sensory organs and vessels. Some organs (heart, gut, spleen, kidney) receive both sympathetic and parasympathetic innervation, while other organs (adrenal, medulla, vascular tissue, skin and muscles) gain only a sympathetic supply. Vegetative nervous system, clinically speaking, is not so autonomus as we believe and seems to be "synergic rather than antagonistic".[31,32,33]
SEGMENTAL DISTRIBUTION OF ACU-POINTS
Three big main meridians cross the frontal thoracic and the frontal abdominal wall. The M of the Spleen, Stomach, Kidney and the Conception Vessel Meridian. During their course via abdominal and thoracic wall, this meridians develop 66 ipsilateral points (110 bilateral) Independently of the name of the meridian, if we apply acupuncture to the points found on the thoracic area, we influence the thoracic viscera or their functions, while when we apply acupuncture, using the points developing into meridians of the frontal abdominal wall, we influence the abdominal viscera or their functions. Moreover, all the meridians follow a course towards the middle frontal and the middle dorsal line similar to the segmental distribution of the deep pain that Keelgren [34] has put on a chart after injection of NaCl in the interspinal ligaments of the vertebrae. The dermotomal distribution of the sympathetic fibres coincides with the distribution of the points of acupuncture of the second branch of the Meridian of the urinary bladder.
The same accurate neurotomic distribution of the acupuncture points seems to be preserved by the Urinary Bladder Meridian with the Governing Vessel Meridian. The acupuncture points Lung 1 and 2, Urinary Bladder 13, 14, 15, 41 and Governing Vessel 14, have been used for centuries by acupuncturers for the treatment of lung diseases . All these points concern T2 T4 dermotome of the lungs and they correspond dermotomically to the outlets of the sympathetic chain of the dorsal lung plexus (2nd 4th thoracic sympathetic ganglion). The big bronchial tubes are autonomously innervated by this sympathetic plexus, and also the division of the trachea and all the vessels which transport blood to the bronchial tree. From the same anatomical region start the preganglionic branches of the lower cervical and of the first and the second thoracic ganglion of the sympathetic chain, which are going to form in the depths of the dorsal cervical triangle, the stellar ganglion. The shu-mu technique (synchronus stimulation of abdominal-mu and thoracic, back-shu, points) is a special ancient method that uses the segmental distribution of acu-points to treat diseases of internal abdominal organs.
GENERAL ACTION OF ACUPUNCTURE STIMULATION
Teams of neurophysiologists and research workers on the effect of acupuncture, of electroacupuncture, of electrotherapy and other methods of physical agens have studied the possible mechanisms and the ways of analysing of the peripheral stimulation from the CNS and also the way of answering of the CNS to these stimuli. The integrity of the peripheral nervous system and the spinal cord is considered necessary for the application of acupuncture. It is well known that acupuncture points are «silent» in paraplegic limps (individuals with complete sensory-motor paraplegia) or in experimental animals in which surgical resection of the spinal cord has been effected.[35]
A peripheral stimulus, depending on its quality, may stimulate specific nuclei of the CNS and provoke secretion or qualitative modification of neurotransmitting substances in the blood and the CSF. Besides, each combination of acupuncture points may activates different nerve circuits. This view was based on two experimental results from the University of Peking.[36]
Experiments on rabbits have shown that following arterial anastomosis of two rabbits (cross circulation technique), analgesia is achieved not only for the rabbit on which acupuncture is applied but also for the rabbit in which the blood of the former circulated through the anastomosis. Furthermore, a CSF transfusion from a cat-donor to which acupuncture analgesia had been applied to another cat-receptor causes analgesia to the donor cat after 10 minutes. Since then, the existence (following acupuncture) of analgesic neurotransmitting substances to the CSF and peripheral blood has been repeatedly confirmed and this clearly shows the activation of central pain control systems (and others) through ancient acu points. Reference to these points is related on one hand to the topographical paradox of the points and on the other to their important therapeutic action. Their particularity has been established both by studies (on experimental animals) and clinically (on patients) and it is well known that randomly selected sham acu-points have an analgesic effect on 28-35% of patients when compared to acu points that have an analgesic effect on 55%-85% of the patients. Papers published from time to time relate to acu points Lung (L) 7, Stomach (S) 36, Large intestine (LI) 4, Spleen (Sp) 6, Large Intestine (LI) 10, Triple Heater (TH) 5, Liver (Liv) 3 and Pericardium (P) 6. The systems activated through these points may be a) opiate endogenous analgesic systems, b) non-opiate systems and c) central sympathetic pain inhibition systems through the reticular formation of the brain.
In recent years, the analgesic action of acupuncture is used for the treatment of cases with acute or chronic pain and less for the surgical analgesia it can offer influencing the chemistry of the descending pain control system. This system consists of four parts: a)spinal system (dorsal horn), b) cortical and diencephalic system, c) mesencephalic (PAG & PVG) system and d) pontine (nucleus raphe magnus) system. Each system uses differente types of endogenous opioid peptides.[37,38] There is clear evidence of the analgesic action of acupuncture in this field. I mention that of 1500 articles in Medline, 1100 concern the pain-killing and the analgesic action of acupuncture. The most important among these articles concern laboratory studies on experimental animals and clinical studies in veterinarian clinics.
This fact excludes suggestion (animals cannot be subject to suggestion), hypnosis, placebo effect (in part) but not stress-induced analgesia.
Pomeranz,[6] mention the following results in support of the analgesic (endorphinergic) action of acupuncture: Four different opiate antagonists abolish the analgesic action of acupuncture. Naloxone abolishes the analgesic effect. A microinfusion of naloxone or the infusion of endorphin antibodies (to the CNS) abolish the analgesic effect. Mice with a genetically reduced concentration of opiate receptors in the CNS have a poor response to acupuncture. Rabbits with endorphin deficiency do not respond to the acupuncture stimulus. Endorphin levels increase considerably in peripheral blood and in the cerebrospinal fluid during electro-acupuncture while on the contrary their levels in the CNS are reduced. The analgesic effect of acupuncture lasts much more when one impedes the enzymatic degradation of endorphin. The analgesic effect of acupuncture is transmitted through the blood (cross circulation) and the cerebrospinal fluid. The inhibition of pituitary endorphin abolishes the acupuncture effect. An increase of messenger RNA for pro-enkephalin in the brain (pituitary) is observed for 24-48 hours following acupuncture.
About 60% of patients suffering from myofascial pain of the lumbar portion of the spinal cord are considerably relieved after the application of warm compresses (43-51°C) or ultrasound and the improvement of symptoms lasts from 90 minutes to 7 days. On the contrary, the application of electroacupuncture to general acu points relieves the patients for weeks, months or up to 3 years. This was noted (from Price at al.) on 58% of the patients with chronic myofascial pain of the lumbar portion of the spinal cord to which acupuncture was applied . Han suggests that the specific, long-term analgesic effect of acupuncture is due to two factors: a) the activation of a neurogenous serotonin and methencephalin circuit in the upper part of the descending pain inhibition system (in the mid diencephalon). This results in the continuous inhibition (at the level of the spinal cord) and the non-conduction of harmful stimuli from the spinal cord to the CNS, and therefore the non-perception of pain and b) the (peripheral) activation of low-threshold muscular mechanic receptors. In this manner there is an increase of the activity of thick-diameter nerve fibres (pain modulating system) and a long-lasting inhibition of muscular pain. The long-term pain-killing effect of acupuncture is the most difficult point of contemporary theories. Han's theory (1987 - mesolimbic analgesia system) may be the explanation for one of the acupuncture analgesic mechanisms[39]. At least, activation of "Diffuse Noxious Inhibitory Controls" (DNIC) triggered by nociceptive peripheral stimuli that activates Aä and C fibers (some formes of acupuncture and moxa) can be an other mechanism of central action of acupuncture and involves complex loops from spinal and supraspinal structures[40,41]. From these studies came as a result that neurotransmitting substances, opioid and non-opioid substances of spinal cord and CNS are the main co-ordinators of the "stimulation - analysis - response" phenomenon and they are responsible for the generalised internal chemical reactions of the organism that follows an acupuncture treatment.
There are many findings that acupuncture act at a spinal (segmental or regional) level. Noxious stimuli from the periphery lead to release peptides in the spinal cord level. These peptides (tachykinins substance P, neurokinin A, calcitonine gene-related peptide, somatostatin etc) modulate the transmition of nociceptive information to the CNS. Using treatment modalities like TENS, Acupuncture and electroacupuncture, we can block the nonociceptive signals, activating descending pain inhibitory systems which act at the level of the specific myelotome. Acupuncture and electroacupuncture have an inhibitory effect on interneurons of the spinal cord (lamina V) and this inhibition is mediated by opiate pain-relieving system.[17] Also, many laboratories have shown changes in dorsal horn cell activity (gating) during mechanical, chemical and electrical stimulation of somatic and visceral fields. Transcutaneous electrical nerve stimulation (TENS) of somatic areas dicreases the spontaneous and noxiously evoked activity of a majority of dorsal horn neurons (wide-dynamic-range (WDR) cells, High threshold (HT) cells, and high threshold inhibitory (HTi) cells), reducing the perception of pain. [18]
This mechanism can be the spinal (regional) action of many analgesic physical methods which we use in daily practice in physiotherapy. Another regional reaction concerns the activation of an area through reflex arches. Those are produced after the stimulation of a peripheral sensory receptor. The stimulus is directed with afferent neural fibers to a sensory or motor nucleus of the spinal cord and a response reaction is produced there.
Analytically:
Viscero-cutaneous reflex or splanchno-fascial reflex. According to that, a functional or organic disease of a viscera causes pain, hypalgesia, tension or irritation to a particular area of the skin. As a general rule, the skin area where pain is projected has, in relation to the painful viscera, common somotomic origin as to the embryo and consequently it is innervated sensorially from the same neurotome of the spinal cord. The skin and the related viscera have the same segmental innervation usually by dorsal roots, spinal nerves and nuclei (referred pain resulting from reflex phenomena). The nociceptive impulses from the affected viscera pass to the dorsal horn and then to anterior horn of spinal cord across interneurons. Visceral afferent nociceptors converge on the same pain projection neurons as the afferents from the skin.[19,20,21,22]
For example, stimulation of the descending colon with barium chloride is going to create paleness (shrinking of the melanin cells-melanocytes) in an area or 2-3 neurotomes of the specific myelotomes (T9-T12). Moreover, injection of adrenaline 10% to the stomach gastric mucosa, in the gall bladder or in the fascia of the spleen, is going to create skin «shining» at a specific small area of the dermotomes of those organs. [23]
Pain in the gall bladder is projected on the skin of the right hypochondrium and on the top part of the right shoulder, a pain related to stomach ulcers corresponding to the 11th thoracic vertebra. The viscero cutaneous reflex we have just described is transmitted via the sympathetic chain. Dissection of the spinal cord does not affect this reflex. It is abolished by the dissection of the sympathetic chain. This reflex is a diagnostic reflex.
Cutaneous visceral reflex . The irritation of a skin point influences functionally the organ by which the cutaneous area is connected according to the neurotomes. Experimentally, to patients with acute angina pectoris the injection of procaine in cutaneous tender points of the anterior thoracic wall brings about fast recession of the precordial pain. Electrical stimulation of the point Futu (L.I. 18) on both sides, provokes analgesia capable of achieving thyroidectomy. This point is found in an area of innervation from the third dorsal cervical spinal nerve. The fascial of the thyroid gland and the above lying skin area where the specific acupuncture point is found are sensorially innervated from the same cervical myelotome. This reflex does not depend on superior brain centres. It follows a clearly neurotomic distribution. Dissection of the visceral nerves abolishes the reflex. Dissection of the vagus nerve does not influence the healing effect. It looks like the myotatic, monosynaptic reflexes. This is a therapeutic reflex.
Viscero-muscular and viscero-visceral or somato-autonomic reflexes are internal reflexes. It is they who interpret muscular contraction and vasocontraction observed in diseases of the internal organs. Sensory fibres from the muscles, the vessels and the affected organ originate from the same myelotome on neighbouring nuclei which are functionally interconnected.[24] This reflex produses reflex spasm of the skeletal muscle (trigger points of m. pectoralis) during myocardial ischemia. Also, through this reflex we interpret muscular pain during the function of the muscle under conditions of limited blood supply.[25] The sensation of needle insertion into somatic nerve endings in the muscle, ascends with afferent impulses to the anterior hypothalamus. Efferent impulses originate from the same reflex centre of hypothalamus, descend to the cholinergic vasodilator nerve and dilate the blood vessels of the muscle. Dissection of the dorsal spinal roots and that of the visceral nerves abolishes this reflex. A kind of viscero-visceral reflex is activated during the direct excitation of a ganglion by placing a needle deeply in the ganglion or all around the ganglion. As an example I would like to mention point SI 18, which is a meeting point of the head of the arm 3 Yang meridians. This point is being acupunctured during acute pain of the muscular - skeletal system. Why this point is so important in treatment of myoskeletal diseases. It is mentioned [26] that application of local anaesthetics to the mucosa overlying the sphenopalatine ganglion can block pain and is extremely effective on myoskeletal pain especially of the neck and back.
The acupuncture point LE 18 and the sphenopalatine ganglion coincide. In this area, there exists the largest collection of neurons in the head outside the brain itself. It is intimately connected to the trigeminal nerve and nucleus, and the superior cervical sympathetic ganglion. It seems to be the final switch between the body and the brain.
Somatomotors or cutaneo-muscular segmental reflexes. A harmful stimulus to the skin stimulates the axons of sensory fibres of groups III and IV of peripheral nerves. The information of stimulation enters the posterior horns of the spinal cord and is transmitted with the help of intermediate neurons to the motor neurons of the anterior horns. This pathway is polysynaptic and permits on one hand control and on the other deviation of sensory stimulation. Thus, the stimulation of a group of sensory receptors on the muscles, tendons or the skin will cause contraction or relaxation of muscles in the stimulated area (segmental distribution of the reflex). In this manner, by a sensory stimulus (puncture) it is possible to enlist neurons on the same or on the opposite side of the initial stimulation. The usual response to the sensory stimulus is the ipsilateral stimulation of flexors and the inhibition (relaxation) of extensors and the contralateral inhibition of flexors and stimulation of extensors (flexor and cross-extensor reflex).[27,28] Most rehabilitation treatments by electrophysical agens and, of course, acupuncture, use cutaneo-muscular reflexes to achieve muscle relaxation and to ameliorate the intramuscular blood supply to individual muscles or muscular groups. The selection of the area to be stimulated depends on the target muscle.
Vegetative reflexes are reflexes through the vegetative nervous system (sympathetic and parasympathetic). There is a large number of short and long vegetative reflexes which "close" the nervous circuit in the brain, the spinal cord, in the big nervous ganglia or in smaller peripheral ganglia. There are not only segmental reflexes. Many vegetative reflexes have been describe in medicine. As an example I will mention the segmental and suprasegmental reflexes that are prodused due to local biochemical changes and tissue damage in patiens with acute myocardial ischemia (AMI). This reflex is known as Bezold-Jarich reflex (abnormal vagovagal reflex) and produce severe bradycardia, peripheral vasodilation, severe hypotension and atrioventricular block. These reflexes involves afferents and efferents of both cardiac vagi and cardiac sympathetic nerves which produse sympathosympathetic reflexes. In the AMI patiens exist also suprasegmental reflex responses result from nociceptively induced stimulation of the medullary centers, hypothalamic centers, limbic structures and neuroendocrine function.[29]
According to Gunn, some other common condition of autonomic dysfunction that responce well to acupuncture treatment are the vasomotor, sudomotor, glandular hyperactivity and smooth muscle spasm observing in spondylotic radiculopathy. When pain dissapeare, this autonimic phenomena dissapeare.
Vegetative reflexes can be activated by a) local stimuli, b) general stimuli and c) regional stimuli. From the university of Goteborg [30] we have the information that acupuncture may affect the sympathetic system via mechanism at the hypothalamic and brainstem levels and the post-stimulatory sympathetic inhibition that creates, persist for more that 12 hours after acupuncture.
Vegetative reflexes are the clearest evidence of the organisms reaction as an open thermodynamic system. We know very little about these reflexes. The major problem is in describing the connections between the human cortex and the peripheral outflow to smooth muscles, cardiac muscles, secreting glands, sensory organs and vessels. Some organs (heart, gut, spleen, kidney) receive both sympathetic and parasympathetic innervation, while other organs (adrenal, medulla, vascular tissue, skin and muscles) gain only a sympathetic supply. Vegetative nervous system, clinically speaking, is not so autonomus as we believe and seems to be "synergic rather than antagonistic".[31,32,33]
SEGMENTAL DISTRIBUTION OF ACU-POINTS
Three big main meridians cross the frontal thoracic and the frontal abdominal wall. The M of the Spleen, Stomach, Kidney and the Conception Vessel Meridian. During their course via abdominal and thoracic wall, this meridians develop 66 ipsilateral points (110 bilateral) Independently of the name of the meridian, if we apply acupuncture to the points found on the thoracic area, we influence the thoracic viscera or their functions, while when we apply acupuncture, using the points developing into meridians of the frontal abdominal wall, we influence the abdominal viscera or their functions. Moreover, all the meridians follow a course towards the middle frontal and the middle dorsal line similar to the segmental distribution of the deep pain that Keelgren [34] has put on a chart after injection of NaCl in the interspinal ligaments of the vertebrae. The dermotomal distribution of the sympathetic fibres coincides with the distribution of the points of acupuncture of the second branch of the Meridian of the urinary bladder.
The same accurate neurotomic distribution of the acupuncture points seems to be preserved by the Urinary Bladder Meridian with the Governing Vessel Meridian. The acupuncture points Lung 1 and 2, Urinary Bladder 13, 14, 15, 41 and Governing Vessel 14, have been used for centuries by acupuncturers for the treatment of lung diseases . All these points concern T2 T4 dermotome of the lungs and they correspond dermotomically to the outlets of the sympathetic chain of the dorsal lung plexus (2nd 4th thoracic sympathetic ganglion). The big bronchial tubes are autonomously innervated by this sympathetic plexus, and also the division of the trachea and all the vessels which transport blood to the bronchial tree. From the same anatomical region start the preganglionic branches of the lower cervical and of the first and the second thoracic ganglion of the sympathetic chain, which are going to form in the depths of the dorsal cervical triangle, the stellar ganglion. The shu-mu technique (synchronus stimulation of abdominal-mu and thoracic, back-shu, points) is a special ancient method that uses the segmental distribution of acu-points to treat diseases of internal abdominal organs.
GENERAL ACTION OF ACUPUNCTURE STIMULATION
Teams of neurophysiologists and research workers on the effect of acupuncture, of electroacupuncture, of electrotherapy and other methods of physical agens have studied the possible mechanisms and the ways of analysing of the peripheral stimulation from the CNS and also the way of answering of the CNS to these stimuli. The integrity of the peripheral nervous system and the spinal cord is considered necessary for the application of acupuncture. It is well known that acupuncture points are «silent» in paraplegic limps (individuals with complete sensory-motor paraplegia) or in experimental animals in which surgical resection of the spinal cord has been effected.[35]
A peripheral stimulus, depending on its quality, may stimulate specific nuclei of the CNS and provoke secretion or qualitative modification of neurotransmitting substances in the blood and the CSF. Besides, each combination of acupuncture points may activates different nerve circuits. This view was based on two experimental results from the University of Peking.[36]
Experiments on rabbits have shown that following arterial anastomosis of two rabbits (cross circulation technique), analgesia is achieved not only for the rabbit on which acupuncture is applied but also for the rabbit in which the blood of the former circulated through the anastomosis. Furthermore, a CSF transfusion from a cat-donor to which acupuncture analgesia had been applied to another cat-receptor causes analgesia to the donor cat after 10 minutes. Since then, the existence (following acupuncture) of analgesic neurotransmitting substances to the CSF and peripheral blood has been repeatedly confirmed and this clearly shows the activation of central pain control systems (and others) through ancient acu points. Reference to these points is related on one hand to the topographical paradox of the points and on the other to their important therapeutic action. Their particularity has been established both by studies (on experimental animals) and clinically (on patients) and it is well known that randomly selected sham acu-points have an analgesic effect on 28-35% of patients when compared to acu points that have an analgesic effect on 55%-85% of the patients. Papers published from time to time relate to acu points Lung (L) 7, Stomach (S) 36, Large intestine (LI) 4, Spleen (Sp) 6, Large Intestine (LI) 10, Triple Heater (TH) 5, Liver (Liv) 3 and Pericardium (P) 6. The systems activated through these points may be a) opiate endogenous analgesic systems, b) non-opiate systems and c) central sympathetic pain inhibition systems through the reticular formation of the brain.
In recent years, the analgesic action of acupuncture is used for the treatment of cases with acute or chronic pain and less for the surgical analgesia it can offer influencing the chemistry of the descending pain control system. This system consists of four parts: a)spinal system (dorsal horn), b) cortical and diencephalic system, c) mesencephalic (PAG & PVG) system and d) pontine (nucleus raphe magnus) system. Each system uses differente types of endogenous opioid peptides.[37,38] There is clear evidence of the analgesic action of acupuncture in this field. I mention that of 1500 articles in Medline, 1100 concern the pain-killing and the analgesic action of acupuncture. The most important among these articles concern laboratory studies on experimental animals and clinical studies in veterinarian clinics.
This fact excludes suggestion (animals cannot be subject to suggestion), hypnosis, placebo effect (in part) but not stress-induced analgesia.
Pomeranz,[6] mention the following results in support of the analgesic (endorphinergic) action of acupuncture: Four different opiate antagonists abolish the analgesic action of acupuncture. Naloxone abolishes the analgesic effect. A microinfusion of naloxone or the infusion of endorphin antibodies (to the CNS) abolish the analgesic effect. Mice with a genetically reduced concentration of opiate receptors in the CNS have a poor response to acupuncture. Rabbits with endorphin deficiency do not respond to the acupuncture stimulus. Endorphin levels increase considerably in peripheral blood and in the cerebrospinal fluid during electro-acupuncture while on the contrary their levels in the CNS are reduced. The analgesic effect of acupuncture lasts much more when one impedes the enzymatic degradation of endorphin. The analgesic effect of acupuncture is transmitted through the blood (cross circulation) and the cerebrospinal fluid. The inhibition of pituitary endorphin abolishes the acupuncture effect. An increase of messenger RNA for pro-enkephalin in the brain (pituitary) is observed for 24-48 hours following acupuncture.
About 60% of patients suffering from myofascial pain of the lumbar portion of the spinal cord are considerably relieved after the application of warm compresses (43-51°C) or ultrasound and the improvement of symptoms lasts from 90 minutes to 7 days. On the contrary, the application of electroacupuncture to general acu points relieves the patients for weeks, months or up to 3 years. This was noted (from Price at al.) on 58% of the patients with chronic myofascial pain of the lumbar portion of the spinal cord to which acupuncture was applied . Han suggests that the specific, long-term analgesic effect of acupuncture is due to two factors: a) the activation of a neurogenous serotonin and methencephalin circuit in the upper part of the descending pain inhibition system (in the mid diencephalon). This results in the continuous inhibition (at the level of the spinal cord) and the non-conduction of harmful stimuli from the spinal cord to the CNS, and therefore the non-perception of pain and b) the (peripheral) activation of low-threshold muscular mechanic receptors. In this manner there is an increase of the activity of thick-diameter nerve fibres (pain modulating system) and a long-lasting inhibition of muscular pain. The long-term pain-killing effect of acupuncture is the most difficult point of contemporary theories. Han's theory (1987 - mesolimbic analgesia system) may be the explanation for one of the acupuncture analgesic mechanisms[39]. At least, activation of "Diffuse Noxious Inhibitory Controls" (DNIC) triggered by nociceptive peripheral stimuli that activates Aä and C fibers (some formes of acupuncture and moxa) can be an other mechanism of central action of acupuncture and involves complex loops from spinal and supraspinal structures[40,41]. From these studies came as a result that neurotransmitting substances, opioid and non-opioid substances of spinal cord and CNS are the main co-ordinators of the "stimulation - analysis - response" phenomenon and they are responsible for the generalised internal chemical reactions of the organism that follows an acupuncture treatment.
ELECTROACUPUNCTURE
Electroacupuncture analgesia is a well established phenomenon [42,43,44]. In general, the lower the pulse repetition rate of electrical stimulation, the lower the time required to reach maximum analgesic effect and the longer the effect remains. The higher the pulse repetition rate, the shorter the time required to optain maximum pain threshold, and the effects remain for a shorter time ( table 2 and 3). Also, periaqueductal central gray (PAG) stimulation produced analgesia is similar to acupuncture analgesia in many respects.
According to other studies Xie-Guo-Xi, Han-Ji Sheng (1985) the high frequency of stimulation of the points of acupuncture has above all metameric local action while, on the contrary, low frequency (1-15 HZ) generalized analgesic action. In cases of dissection of the spinal cord all frequencies are inadequate.
Electroacupuncture to a frequency of 2 HZ provokes analgesia mainly through methionine- enkephaline, with 100 HZ mainly through A dynorphine while with 15 HZ both neurotransmitting sybstances are detected in almost equal quantities. There is more recent work (especially on high frequency current) in which it is held that the stimulation at a frequency in excess of 10 Hz increases enzymatic degradation of circulating opiate substances reducing the analgesic effect.[45]
Also, new electrotherapy techniques (MENS - microcurrent electrical neuromuscular stimulation) and electroacupuncture with current intensities in the order of 400 ìÁ at 10-60 Volts (low voltage pulsed microamp stimulation) and extremely long pulse duration with total current equal to 5x10-6 coulombs/sec, are awaiting the results of the clinical tests to which they are subjected [46,47]. This technique is based to Arudt-Schulz law that microamperage (ìA) currents are better at enhancing cellular physiology processes than are currents of higher amplitude. Several clinical studies have documented the enhancing effects of MENS on wound healing, on tendon repair in animal models, on recovery of injured athletes suffering from ruptured ligaments and tendons. Also, laboratory studies shows the ability to MENS device to stimulate cellular physiology and grouth (increased ATP by almost 500%, increased membrane transport by 30-40% and increase protein synthesis by up to 73%).
The endogenous opioid peptides such as endorphine, enkephalin and others are not related exclusively to pain. They are directly related to all forms of dependence (drugs, smoking, alcoholism). Low levels of methionine-encephalin have been found in patients suffering from Parkinson's disease. Very high concentration levels have been reported in the dorsal cochlear nucleus and the intermediate geniculate body in patients suffering of schizophrenia. There is also significant evidence as to their role in the regulation of food intake (obesity). In particular with regard to obesity, it has been found that there is a large number of "saturation" peptides and "stimulating apetite" peptides in the hypothalamic nuclei of the brain and the gastro-intestinal tract, functioning as hormone inhibitors or as neurotransmitters.
It has also been clinically established that acupuncture acts on the following body systems [48] (table 4). The action on the above mentioned body systems must be attributed to the ability of acupuncture to influence the function of the Central Nervous System.
The prominent Nobel winning neuroscientist Gerald Edelman [49] mentions that there is no more complex functional structure in the universe than the human brain. The most specialized and exciting type of cell is the neuron. The neuron, the structural unit of the brain, is unusual as regards its shape, its electrical and chemical function and the way in which it connects to other neurons forming networks. Only in the cortex there are about ten billion neurons. Each neuron is connected to others through synapses. It is surprising that there are one million billions of connections in the synapses of the cortex. If we started counting them, at a rate of one synapse per second, we would finish counting after thirty-two million years. One piece of our brain of a size equal to the head of a match contains one billion synapses. If we tried to calculate the many ways in which synapses may be combined, we would have a number consisting of 10 followed by millions of zeroes (the number of positive charged particles in the universe is 10 followed by 80 zeroes). The brain is connected to the outer world through specialized neurons called sensory neurons that form the sensory organs and supply the brain with input signals, while output signals are transported to the brain through neurons connected to muscles and glands. The largest areas of the brain, however, exchange signals with some other areas of the brain without any intervention from the outside world. Edelman points out that the brain is more in contact with itself and the interior of the body than with anything else. The corpus callosum connecting the right to the left hemisphere contains 200 million fibers. The brain tissue is a complex network that communicates electrochemically both to the outer and to the inner environment. It emits and receives dynamic formations of signals and answers to these signals. The formations of its neurons influence the functionality of the heart, the kidneys, the lungs, the muscles, the skin and the glands. The brain regulates breath, digestion, blood circulation and naturally analyses the acupuncture stimulus.
It is very difficult for me to give a solution to the problem of the action of acupuncture. However, it is not difficult to underline the contribution of acupuncture in the balance of the chemistry of our nervous system and of the role of the hundreds of neurotransmitting substances that regulate in whole or in part our health and disease, emotional behavior, instincts, desires and the psychic disposition of man.
It has been noted that depression is related to a disorder of the metabolism of noradrenalin and serotonin. The antidep ressant action of amphetamines and the existence of benzodiazepine receptors in the cerebellum and the limbic system is also known. The role of gamma-aminobutyric acid (GABA), a well-known neurotransmitter for its inhibitory role in neurotransmission (through the K+, Na+, Cl- pump) and its intense ancholytic action is perhaps more general [50,51,52,53].
Acupuncture is used for the treatment of a multitude of functional disorders such as metabolic diseases, endocrine disorders, mental disorders, functional, respiratory and digestive disorders, allergies, neurovegetative disorders etc. Reference of the neuronic theory of the action of acupuncture on these disorders is based on one hand on the investigation of the unknown homeostatic role of the reticular formation of the brain matter and on the other on the multitude of neurotransmitting substances that are detected peripherally following treatment with acupuncture (cholecystokinin, bombesin, neurotensine, CRH (corticotropin releasing factor), dynorphin, neuropeptide Y, encephalins, amines etc.) and in the mode of action, secretion, activation and enzymatic inactivation of the above mentioned substances. It appears that these substances are similar in action to the classical endocrine gland hormones, activating negative and positive feedback mechanisms. The role of acupuncture in these diseases has been only clinically established.
THE RETICULAR FORMATION
The reticular formation consists of groups of neurons and of neural fibres which unite the cerebral nuclei between them and each one separately with subcortical centres, thalamic centres, cerebellum centres, parencephalic centres, medulla oblongata and spinal cord. Functionally, it controls the mechanisms of wakefulness and those of sleep, muscular tonus, level of consciousness, cardiac and respiratory rhythm, vessel tonus, regulating and mediating motor, autonomic and sensory functions.
On the level of the nuclei of the reticular formation is led almost all information concerning sensibility and in a slow rhythm (because of the multiple synapsis) are transformed and analysed qualitatively and quantitatively. As a result of this analysis, the nervous signal coming from the periphery when it reaches the upper centres (brain nuclei) is differentiated from the initial one. That agree with hypothesis that mechanical, thermal and chemical noxious stimuly have effect on neuron activity of medullary and mesencephalic reticular formation especially around nucleus gigantocelularis (NGC). Also, Casey and Meltzack [54] suggested that reticular neurons may mediate the affective/motivasional dimension of the pain experience and pain-related behavior, indicating the role of reticular formation in pain perception and modulation.
This descending modulation system brings significant functional alterations to the peripheral organs. Indeed, implantation of electrodes in areas of the reticular formation of the medulla oblongata and above all outside the cerebral nuclei brought big alterations on a cell, tissue, organic and functional level to the guinea pigs such as hydronephrosis, organic dysplasia, bone deformity etc. It seems that the activating system of the reticular formation regulates the level of wakefulness of the functional nuclei of the central nervous system according to the information it receives from the sensory pathways. It is capable of making thrive or of repressing a multitude of body and psychic symptoms such as worry, dyspnotic phenomena, sweating, insomnia, irritability, change of cardiac and respiratory rhythm, vessel tonus. Interference with the homeostatic mechanisms of the reticular formation can be achieved only through sensory stimulation. Acupuncture can very possibly be a kind of similar stimulation. Particular points such as auricular points Shen Men, Jerome and Master sensorial point, and somatic points such as H7, H3, L.I.3, GB20, ST41, P 6, UB10 act the equilibrating way mainly on the mental diseases and are used on patients with mental disorders intensely somatised.
CONCLUSION
The restoration of morphological and functional homeostasis and the maintenance of the dynamic equilibrium of the body that is gradually restored after acupuncture treatment may be explained only if we consider the body as an open thermodynamic system that may transform exogenous influences from the environment and modify the function of its systems accordingly. This consideration constitutes the theoretical basis of Cybernetic systems (cybernetics: the field that deals most directly with information processing and feedback).
In this manner one can sketch today the therapeutic action of Acupuncture. The profound knowledge of the principles of acupuncture, the mechanism of action and reaction of the organism at a normal and pathological state, the concept of the organism as a unique whole (Hippocrates) the mental follow-up of the meridians where vital energy circulates and the selection of acu points are the most important difficulties that doctors have to face with before understanding, learning and applying acupuncture.
It is a fact that the traditional applications of this therapeutic system that are derived from sources lost in the depths of time and verified in everyday medical practice are for us, western physicians a starting point but also a leading point for contemporary medical research concerns.
I point out that the rejection of a method is not a scientific position. In the history of science, the motive force of progress was the innate tendency towards interpretation (and investigation) of natural phenomena. No matter how many problems we shall face in the preparation of research protocols to establish the action, indications, counter-indications and side effects of acupuncture. Their solution will always be the target of medical science.
Besides, the physician is not obliged to study Chinese Philosophy in order to exercise acupuncture. However it is necessary that he takes in his hands a weapon tested throughout the centuries, enriching his therapeutic armament having as his sole criterion the relief of man from pain.
Electroacupuncture analgesia is a well established phenomenon [42,43,44]. In general, the lower the pulse repetition rate of electrical stimulation, the lower the time required to reach maximum analgesic effect and the longer the effect remains. The higher the pulse repetition rate, the shorter the time required to optain maximum pain threshold, and the effects remain for a shorter time ( table 2 and 3). Also, periaqueductal central gray (PAG) stimulation produced analgesia is similar to acupuncture analgesia in many respects.
According to other studies Xie-Guo-Xi, Han-Ji Sheng (1985) the high frequency of stimulation of the points of acupuncture has above all metameric local action while, on the contrary, low frequency (1-15 HZ) generalized analgesic action. In cases of dissection of the spinal cord all frequencies are inadequate.
Electroacupuncture to a frequency of 2 HZ provokes analgesia mainly through methionine- enkephaline, with 100 HZ mainly through A dynorphine while with 15 HZ both neurotransmitting sybstances are detected in almost equal quantities. There is more recent work (especially on high frequency current) in which it is held that the stimulation at a frequency in excess of 10 Hz increases enzymatic degradation of circulating opiate substances reducing the analgesic effect.[45]
Also, new electrotherapy techniques (MENS - microcurrent electrical neuromuscular stimulation) and electroacupuncture with current intensities in the order of 400 ìÁ at 10-60 Volts (low voltage pulsed microamp stimulation) and extremely long pulse duration with total current equal to 5x10-6 coulombs/sec, are awaiting the results of the clinical tests to which they are subjected [46,47]. This technique is based to Arudt-Schulz law that microamperage (ìA) currents are better at enhancing cellular physiology processes than are currents of higher amplitude. Several clinical studies have documented the enhancing effects of MENS on wound healing, on tendon repair in animal models, on recovery of injured athletes suffering from ruptured ligaments and tendons. Also, laboratory studies shows the ability to MENS device to stimulate cellular physiology and grouth (increased ATP by almost 500%, increased membrane transport by 30-40% and increase protein synthesis by up to 73%).
The endogenous opioid peptides such as endorphine, enkephalin and others are not related exclusively to pain. They are directly related to all forms of dependence (drugs, smoking, alcoholism). Low levels of methionine-encephalin have been found in patients suffering from Parkinson's disease. Very high concentration levels have been reported in the dorsal cochlear nucleus and the intermediate geniculate body in patients suffering of schizophrenia. There is also significant evidence as to their role in the regulation of food intake (obesity). In particular with regard to obesity, it has been found that there is a large number of "saturation" peptides and "stimulating apetite" peptides in the hypothalamic nuclei of the brain and the gastro-intestinal tract, functioning as hormone inhibitors or as neurotransmitters.
It has also been clinically established that acupuncture acts on the following body systems [48] (table 4). The action on the above mentioned body systems must be attributed to the ability of acupuncture to influence the function of the Central Nervous System.
The prominent Nobel winning neuroscientist Gerald Edelman [49] mentions that there is no more complex functional structure in the universe than the human brain. The most specialized and exciting type of cell is the neuron. The neuron, the structural unit of the brain, is unusual as regards its shape, its electrical and chemical function and the way in which it connects to other neurons forming networks. Only in the cortex there are about ten billion neurons. Each neuron is connected to others through synapses. It is surprising that there are one million billions of connections in the synapses of the cortex. If we started counting them, at a rate of one synapse per second, we would finish counting after thirty-two million years. One piece of our brain of a size equal to the head of a match contains one billion synapses. If we tried to calculate the many ways in which synapses may be combined, we would have a number consisting of 10 followed by millions of zeroes (the number of positive charged particles in the universe is 10 followed by 80 zeroes). The brain is connected to the outer world through specialized neurons called sensory neurons that form the sensory organs and supply the brain with input signals, while output signals are transported to the brain through neurons connected to muscles and glands. The largest areas of the brain, however, exchange signals with some other areas of the brain without any intervention from the outside world. Edelman points out that the brain is more in contact with itself and the interior of the body than with anything else. The corpus callosum connecting the right to the left hemisphere contains 200 million fibers. The brain tissue is a complex network that communicates electrochemically both to the outer and to the inner environment. It emits and receives dynamic formations of signals and answers to these signals. The formations of its neurons influence the functionality of the heart, the kidneys, the lungs, the muscles, the skin and the glands. The brain regulates breath, digestion, blood circulation and naturally analyses the acupuncture stimulus.
It is very difficult for me to give a solution to the problem of the action of acupuncture. However, it is not difficult to underline the contribution of acupuncture in the balance of the chemistry of our nervous system and of the role of the hundreds of neurotransmitting substances that regulate in whole or in part our health and disease, emotional behavior, instincts, desires and the psychic disposition of man.
It has been noted that depression is related to a disorder of the metabolism of noradrenalin and serotonin. The antidep ressant action of amphetamines and the existence of benzodiazepine receptors in the cerebellum and the limbic system is also known. The role of gamma-aminobutyric acid (GABA), a well-known neurotransmitter for its inhibitory role in neurotransmission (through the K+, Na+, Cl- pump) and its intense ancholytic action is perhaps more general [50,51,52,53].
Acupuncture is used for the treatment of a multitude of functional disorders such as metabolic diseases, endocrine disorders, mental disorders, functional, respiratory and digestive disorders, allergies, neurovegetative disorders etc. Reference of the neuronic theory of the action of acupuncture on these disorders is based on one hand on the investigation of the unknown homeostatic role of the reticular formation of the brain matter and on the other on the multitude of neurotransmitting substances that are detected peripherally following treatment with acupuncture (cholecystokinin, bombesin, neurotensine, CRH (corticotropin releasing factor), dynorphin, neuropeptide Y, encephalins, amines etc.) and in the mode of action, secretion, activation and enzymatic inactivation of the above mentioned substances. It appears that these substances are similar in action to the classical endocrine gland hormones, activating negative and positive feedback mechanisms. The role of acupuncture in these diseases has been only clinically established.
THE RETICULAR FORMATION
The reticular formation consists of groups of neurons and of neural fibres which unite the cerebral nuclei between them and each one separately with subcortical centres, thalamic centres, cerebellum centres, parencephalic centres, medulla oblongata and spinal cord. Functionally, it controls the mechanisms of wakefulness and those of sleep, muscular tonus, level of consciousness, cardiac and respiratory rhythm, vessel tonus, regulating and mediating motor, autonomic and sensory functions.
On the level of the nuclei of the reticular formation is led almost all information concerning sensibility and in a slow rhythm (because of the multiple synapsis) are transformed and analysed qualitatively and quantitatively. As a result of this analysis, the nervous signal coming from the periphery when it reaches the upper centres (brain nuclei) is differentiated from the initial one. That agree with hypothesis that mechanical, thermal and chemical noxious stimuly have effect on neuron activity of medullary and mesencephalic reticular formation especially around nucleus gigantocelularis (NGC). Also, Casey and Meltzack [54] suggested that reticular neurons may mediate the affective/motivasional dimension of the pain experience and pain-related behavior, indicating the role of reticular formation in pain perception and modulation.
This descending modulation system brings significant functional alterations to the peripheral organs. Indeed, implantation of electrodes in areas of the reticular formation of the medulla oblongata and above all outside the cerebral nuclei brought big alterations on a cell, tissue, organic and functional level to the guinea pigs such as hydronephrosis, organic dysplasia, bone deformity etc. It seems that the activating system of the reticular formation regulates the level of wakefulness of the functional nuclei of the central nervous system according to the information it receives from the sensory pathways. It is capable of making thrive or of repressing a multitude of body and psychic symptoms such as worry, dyspnotic phenomena, sweating, insomnia, irritability, change of cardiac and respiratory rhythm, vessel tonus. Interference with the homeostatic mechanisms of the reticular formation can be achieved only through sensory stimulation. Acupuncture can very possibly be a kind of similar stimulation. Particular points such as auricular points Shen Men, Jerome and Master sensorial point, and somatic points such as H7, H3, L.I.3, GB20, ST41, P 6, UB10 act the equilibrating way mainly on the mental diseases and are used on patients with mental disorders intensely somatised.
CONCLUSION
The restoration of morphological and functional homeostasis and the maintenance of the dynamic equilibrium of the body that is gradually restored after acupuncture treatment may be explained only if we consider the body as an open thermodynamic system that may transform exogenous influences from the environment and modify the function of its systems accordingly. This consideration constitutes the theoretical basis of Cybernetic systems (cybernetics: the field that deals most directly with information processing and feedback).
In this manner one can sketch today the therapeutic action of Acupuncture. The profound knowledge of the principles of acupuncture, the mechanism of action and reaction of the organism at a normal and pathological state, the concept of the organism as a unique whole (Hippocrates) the mental follow-up of the meridians where vital energy circulates and the selection of acu points are the most important difficulties that doctors have to face with before understanding, learning and applying acupuncture.
It is a fact that the traditional applications of this therapeutic system that are derived from sources lost in the depths of time and verified in everyday medical practice are for us, western physicians a starting point but also a leading point for contemporary medical research concerns.
I point out that the rejection of a method is not a scientific position. In the history of science, the motive force of progress was the innate tendency towards interpretation (and investigation) of natural phenomena. No matter how many problems we shall face in the preparation of research protocols to establish the action, indications, counter-indications and side effects of acupuncture. Their solution will always be the target of medical science.
Besides, the physician is not obliged to study Chinese Philosophy in order to exercise acupuncture. However it is necessary that he takes in his hands a weapon tested throughout the centuries, enriching his therapeutic armament having as his sole criterion the relief of man from pain.
«Each addition of knowledge is an addition of human power».
HORATIO
HORATIO
REFERENCES
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2. Bonica, J., Procacci, P., General considerations of acute pain In: John Bonica, The management of pain. Lea & Febiger ed. Philadelphia, 1990, pp. 159-178.
3. Rush, T.C., Pathophysiology of pain. In: Medical physiology and biophysics, 18th ed. W.B.Saunders, Philadelphia, 1960, pp. 350-368.
4. Morley, J.A., Visceral pain, Br. Med. J. vol 2, p. 1270, 1937.
5. Sinclair, D.C., Weddell, G., Feidel, W.H. Referred pain and associated phenomena. Brain, vol 71, p. 184, 1948.
6. Stux, G., Pomeranz, B., Basics of Acupuncture, Springer-Verlang, Berlin Heidelberg, 1991, pp. 6-7.
7. Bischko, J., Intermediate acupuncture, Karl F Hang publ., Heildelberg, 1986, pp. 49.
8. Lee, M.H.M., Liao, J.S., Acupuncture in physiatry In: Kottke, J.F., Lehmann, F.J., Krusen's handbook of physical medicin and rehabilitation, W.B.Saunders Co, Philadelphia, 1990, pp. 402-427.
9. Watkins, L.R., Mayer, D.J.: organization of endogenous opiate and non-opiate pain control systems. Science, vol. 216, pp. 1185-1192, 1982.
10. Becher, R., Selden, G.: The body electric. Electromagnetism and the foundation of life. Ed. W.Morrow, New York, 1985.
11. Tirgoviste, I. Teoria si practica acupuncturii moderne, Ed. Academiei Romane, Bucuresti, 1993, pp. 201-248.
12. Rosenthal, S.R., Sonnenschein, R.R. Histamine as a possible chemical mediator for coutaneous pain. Am. J. Physiol. Vol. 155, pp. 186-190, 1948.
13. Bonica, J., Yaksh, T., Liebeskind, J.C., Pechnick, R.N., Depantis, A. Biochemistry and modulation of nociception and pain, In: John Bonica, The management of pain. Lea & Febiger ed. Philadelphia, 1990, pp. 96-120.
14. von Euler, U.S., Gaddum, J.H.: An unidentified depressive substance in certain tissue extracts. J. Physiol., vol. 72, p. 74, 1931.
15. Travell, G.F., Simons, G.D., Myofascial pain and dysfunction, Williams and Wilkins ed., Baltimore, U.S.A., 1992, pp.1-4.
16. Meltzack, R., Stillwell, D.M., Fox, E.J.: Trigger points and acupuncture points for pain correlation and implications. Pain, vol. 3, pp. 3-23, 1977.
17. Cheng, S.S.R., Neurophysiology of electroacupuncture analgesia In: B. Pomeranz, G. Stux, Scientific bases of acupuncture, Springer-Verlag Ed., Germany, 1989, pp. 119-135.
18. Garrison, W.D., Foreman, D.R., Deacreased activity of spontaneous and noxiously evoked dorsal horn cells during transcutaneous electrical nerve stimulation (TENS), Pain vol. 48, pp. 309-315, 1994.
19. Fields, H.L.: Pain. New York, McGraw-Hill, 1978, pp. 90-91.
20. Meyer, R.A., Campbell, J.N., Raja, S.N.: Peripheral neural mechanisms of cutaneous hyperalgesia, In: Advances in pain research and therapy, vol 9, ed. H.L.Fields, R. Dubner, F. Cervero. New York, Raven press, 1985, pp.53-71.
21. Kellgren, J.H., On the distribution of pain arising from deep somatic structures with charts of segmental pain areas. Clin. Sci. vol. 4, pp. 35, 1939.
22. Kellgren, J.H.: Observations on referred pain arising from muscle. Clin. Sci., vol. 3, pp. 176, 1937.
23. Mann, F., Scientific aspects of acupuncture, William Heinemann med. Books ltd., London, 1977, pp.10-18.
24. Takeshire, C., Mechanism of acupuncture analgesia based on animal experiments, In: Pomeranz, B., Stux, G., Scientific bases of acupuncture, Springer-Verlang Berlin, Heidelberg, 1989, pp. 53-74.
25. Le Bars, D., Willer, J.C., de Broncker, T., Villanneva, L., Neurophysiological mechanisms involved in the pain-relieving effects of counterirritation and related techniques including acupuncture, In: Pomeranz, B., Stux, G., Scientific bases of acupuncture, Springer-Verlang Berlin, Heidelberg, 1989, pp. 79-105.
26. Russell, A., Scudds, A.R., Sheno-palatine ganglion bloch: the final gate to switching off pain? , J. Musculoskel. Pain, vol 2, pp. 137-141, 1994.
27. Murray, M., Spinal Cord, In: Conn, P. M., Neuroscience in medicine, J. B. Lippicott Co, Philadelphia, 1995, pp. 197-209.
28. Waxman, G.S., De Groot, J., Correlative neuroanatomy, Appleton & Lange, USA, 1995.
29. Hammermeister, E.K., Cardiac and aortic pain, In: J.Bonica, The management of pain, Lea & Febiger, Philadelphia, 2nd ED. Vol. 2, 1990, pp. 1001-1016.
30. Anderson, S.L.: Acupuncture: from empiricism to science: Functional background to acupuncture effects in pain and disease. Med. Hypotheses, vol. 45 (3), pp. 271-281, 1995.
31. Pruna, S., Bajenaru, O., Gheta, O.,Mota, M., Karavis, M., Golcea, D. Neurovegetative responce recorded by a reactometry as indicator of receptivity to acupuncture. Bucharest, 1986.
32. Karavis, M. Relationships between electrical skin potentials, perception threshold to an electric stimulus and the vibrated sensitivity to patiens with or without diabetic neuropathy (Dissertation), Bucharest: University of Bucharest, 1985.
33. Basmajian, V.J.: Biofeedback, Ed. Williams & Wilkins, 3rd ed., USA, 1989, pp. 17-27.
34. Kellgren, J. H. On distribution of pain arising from deep somatic structures with charts of segmental pain, Clinical science vol. 4, pp. 35-46, 1939.
35. Macdonald, A., Acupuncture analgesia, transcutaneous nerve stimulation (TNS) and vascular effects In: Wall, P.D., Meltzack, R. Textbook of pain, (2nd ed.) Churchill Livingstone, Edinburgh, 1989.
36. Niboyet, J.E.H., L'anesthesie par l'acupuncture, Ed Maisonneuve, France, 1973, pp. 59-94.
37. Zhu, L., Jiang, J.W., Wu, G.C., Cao, X.D. : Changes of endogenous opioid peptides content in RPGL during acupuncture analgesia, Shen Li Hsueh Pao, vol. 45 (1), 1993, pp. 36-43.
38. Zhou, L., Wu, G.C., Cao, X.D.: Role of opioid peptides of rat's nucleus reticularis paragigantocellularis lateralis (RPGL) in acupuncture analgesia, Acupunct. Electrother. Res., vol. 20 (2), 1995, pp. 89-100.
39. Baldry, P.E., Acupuncture, trigger points and musculoscheletal pain, Churchill Livingstone, 2nd Ed , 1993, pp. 120-124.
40. Le Bars, D., Calvino, B., Villanneva, L., Cadden, S., Physiological approaches to counterirritation phenomena In: Trickelbank M.D., Curzon, G., Stress induced analgesia, Wiley Chichester, 1984, pp. 67-101.
41. Le Bars, D., Chitour, D., Clot, A.M., The encoding of thermal stimuli dy diffuse noxious inhibitory controls (DNIC), Brain Res, Vol 230, pp. 394-399, 1981.
42. Anderson, S.A., Ericson, T., Holmgren, E., Lindqvist, G., Electroacupuncture. Effect on pain threshold measured with electrical stimulation of teeth. Brain, vol. 63, 1973, pp. 393-396.
43. Sheng, R.S.S., Neurophysiology of acupuncture analgesia, In: Pomeranz, B., Stux, G., Scientific bases of acupuncture, Springer-Verlang Berlin, Heidelberg, 1989, pp. 119-135.
44. Takeshige, C., Murai, M., Hachisu, M., Parallel individual variation in effectiveness of electro-acupuncture, morphine analgesia and dorsal PAG-SPA and its abolishment by D-phenylalanine, Acupunt. & Electro-ther. Res., Int. J, Vol 5, pp. 251-268, 1980.
45. Omura, Y., Sophia symposium of acupuncture, 1994.
46. Picker, I.R., Low volt pulsed microamp stimulation, Clinical management, vol. 9, 1985.
47. Scott, O., Sensory and motor nerve activation, In: Kitchen, S., Bazin, S., Clayton's electrotherapy, W.B. Saunders Co, London, 1994, pp. 61-80.
48. Omura, Y., Patho-physiology of the acupuncture tratment, In: Warren, Z.F.: Handbook of medical acupuncture Van Nostrand Reinhild Co., New York, 1976, pp. 87-121.
49. Edelman, M.G., Bright air, Brilliant fire, Basics books inc, USA, 1992, pp. 49-60.
50. Barchas, J.D., Akil, H., Elliott, G.R., Holman, R.B., Watson, S.G., Behavioral neurochemistry: neurolegulators and behavioral states. Science, vol. 200, pp.964-973, 1978.
51. Anderson, E.G., Proudfit, H.K., The functional role of the bulbospinal serotoninergic nervous system. The MIT Press, London, pp. 307-338, 1981.
52. Nieuwenhuys, R., Chemoarchitecture of the brain, Springer-Verlag ed. Berlin, 1985.
53. Holaday, J.W., Loh, H.H., Li, C.H., Unique behavioral effects of b-endorphin and their relationship to hypothalamic function, Life science, vol. 22, pp.1525-1536, 1978.
54. Meltzack, R., Casey, K.L., Sensory, motivational and central control determinans of pain, In: The skin senses. Ed. by Kenshalo, J.R., Springfield, I.L., Charles, C.T., 1968, pp. 423-443.
Announced at ICMART '96, VII 's World Congress. Copenhagen, 9 - 12 . 5 . 1996.
1. Stux, G., Pomeranz, B., Basics of Acupuncture, Springer-Verlang, Berlin Heidelberg, 1991, pp. 4-19.
2. Bonica, J., Procacci, P., General considerations of acute pain In: John Bonica, The management of pain. Lea & Febiger ed. Philadelphia, 1990, pp. 159-178.
3. Rush, T.C., Pathophysiology of pain. In: Medical physiology and biophysics, 18th ed. W.B.Saunders, Philadelphia, 1960, pp. 350-368.
4. Morley, J.A., Visceral pain, Br. Med. J. vol 2, p. 1270, 1937.
5. Sinclair, D.C., Weddell, G., Feidel, W.H. Referred pain and associated phenomena. Brain, vol 71, p. 184, 1948.
6. Stux, G., Pomeranz, B., Basics of Acupuncture, Springer-Verlang, Berlin Heidelberg, 1991, pp. 6-7.
7. Bischko, J., Intermediate acupuncture, Karl F Hang publ., Heildelberg, 1986, pp. 49.
8. Lee, M.H.M., Liao, J.S., Acupuncture in physiatry In: Kottke, J.F., Lehmann, F.J., Krusen's handbook of physical medicin and rehabilitation, W.B.Saunders Co, Philadelphia, 1990, pp. 402-427.
9. Watkins, L.R., Mayer, D.J.: organization of endogenous opiate and non-opiate pain control systems. Science, vol. 216, pp. 1185-1192, 1982.
10. Becher, R., Selden, G.: The body electric. Electromagnetism and the foundation of life. Ed. W.Morrow, New York, 1985.
11. Tirgoviste, I. Teoria si practica acupuncturii moderne, Ed. Academiei Romane, Bucuresti, 1993, pp. 201-248.
12. Rosenthal, S.R., Sonnenschein, R.R. Histamine as a possible chemical mediator for coutaneous pain. Am. J. Physiol. Vol. 155, pp. 186-190, 1948.
13. Bonica, J., Yaksh, T., Liebeskind, J.C., Pechnick, R.N., Depantis, A. Biochemistry and modulation of nociception and pain, In: John Bonica, The management of pain. Lea & Febiger ed. Philadelphia, 1990, pp. 96-120.
14. von Euler, U.S., Gaddum, J.H.: An unidentified depressive substance in certain tissue extracts. J. Physiol., vol. 72, p. 74, 1931.
15. Travell, G.F., Simons, G.D., Myofascial pain and dysfunction, Williams and Wilkins ed., Baltimore, U.S.A., 1992, pp.1-4.
16. Meltzack, R., Stillwell, D.M., Fox, E.J.: Trigger points and acupuncture points for pain correlation and implications. Pain, vol. 3, pp. 3-23, 1977.
17. Cheng, S.S.R., Neurophysiology of electroacupuncture analgesia In: B. Pomeranz, G. Stux, Scientific bases of acupuncture, Springer-Verlag Ed., Germany, 1989, pp. 119-135.
18. Garrison, W.D., Foreman, D.R., Deacreased activity of spontaneous and noxiously evoked dorsal horn cells during transcutaneous electrical nerve stimulation (TENS), Pain vol. 48, pp. 309-315, 1994.
19. Fields, H.L.: Pain. New York, McGraw-Hill, 1978, pp. 90-91.
20. Meyer, R.A., Campbell, J.N., Raja, S.N.: Peripheral neural mechanisms of cutaneous hyperalgesia, In: Advances in pain research and therapy, vol 9, ed. H.L.Fields, R. Dubner, F. Cervero. New York, Raven press, 1985, pp.53-71.
21. Kellgren, J.H., On the distribution of pain arising from deep somatic structures with charts of segmental pain areas. Clin. Sci. vol. 4, pp. 35, 1939.
22. Kellgren, J.H.: Observations on referred pain arising from muscle. Clin. Sci., vol. 3, pp. 176, 1937.
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