Chapter 14 Fossil evidence of trepanning suggests that man has used high threshold physical techniques in the treatment of disease since Neolithic times (Martin, 2000; Parry, 1936). Bone etchings from China dating back to 1600 BC are said to provide some of the earliest evidence of acupuncture techniques. Older still are the sharpened stones called Bian shi, although it is questioned whether or not these were actually instruments of acupuncture (Bai & Baron, 2001). Harder evidence—in a softer format—comes from the silk scrolls found in Han Tomb No. 3 (dated to 168 BC) at Mawangdui, Changsha, China, in the early 1970s. These manuscripts describe an early meridian system with 11 rather than 12 paired meridians and the use of moxibustion, which is a treatment involving the application of heat by burning the herb Artemisia vulgaris. The pericardium meridian is missing (Chen, 1997) from these early manuscripts. There is also an emphasis on information derived from tactile examination of the living body (Hsu, 2005) rather than from dissection postmortem. However, there is no description of acupuncture needling in these manuscripts (Bai & Baron, 2001). The discovery of Ötzi, the Tyrolean iceman frozen from 3200 BC, suggests the use of a therapeutic needling technique with a needle made from bone, which may have developed in Europe (Dorfer et al., 1999). It seems clear that acupuncture-like therapies have developed independently in different civilisations around the world; this is probably due to late evolutionary features in the mammalian nervous system, combined with intelligence, and the consequent use of tools in humans. Children learn at a very early age to rub energetically directly over the site of acute pain to reduce the noxious sensation. In the case of a more chronic discomfort from aching, ‘knotted’ muscle, we tend to massage the local tissues more deeply and vigorously even though doing so may temporarily exacerbate the discomfort. This is likely to be conditioned behaviour resulting from the analgaesic effect of somatic sensory stimulation. With the development of stone tools, it is easy to hypothesise a progression of therapeutic techniques that resulted ultimately in piercing the skin and muscle at a site of chronic pain. It may be that successful treatment of myofascial pain by piercing the body at the site of tenderness not only encouraged the practice, but also lead to the recognition of areas of the body that were most likely to harbour these tender points. In some parts of the world, people developed superficial techniques of scratching or cauterising the skin, whereas in the Far and Middle East the technique of acupuncture developed (Cummings, 2004). The development of acupuncture points probably resulted from clinical observation that certain places in the body were more likely to harbour tender points than others and that treating these points by pressure or piercing could relieve pain and various other nonpainful symptoms. Early physicians would have also noted that careful examination of the body surface revealed tender points in healthy subjects. Consistent patterns of pain referral from myofascial trigger points and the relief resulting from needling these and other muscle points would have lead them to make links between some of the points. Radiation patterns of painful medical conditions such as sciatica, other radiculopathies, and possibly the consistent rashes of herpes zoster would have added to the impression that the established points were connected. These hypotheses do not explain the location of all acupuncture points, nor the paths of all the meridians, but there is clearly considerable overlap between myofascial trigger points and acupuncture points (Melzack et al., 1977) and between the pain referral patterns of the former and meridians (Dorsher, 2009). Although these potential correlations have caused great debate, the theoretical backgrounds of these concepts are clearly distinct. The Chinese and others probably used acupuncture pragmatically for centuries before it became systematised within a documented form of medicine some 2000 years ago (Veith, 1972). The theories developed were influenced by rational observations imposed upon a limited clinical knowledge base and in the philosophical framework of Taoism. The tendency towards syncretism resulted in the adoption and inclusion of many different theories; over the centuries this has resulted in the development of a complex system of medicine. Traditional Chinese medicine can be initially unpalatable to the skeptical Western scientist. However, on closer inspection it reveals that it is built on a series of logical assumptions, and, although some of these are clearly wrong, many may still represent valid clinical observations. Western medical acupuncture is a term with a variety of potential meanings. The most literal interpretation invokes thoughts of geographical boundaries, but the term was probably introduced to distinguish a developing system of needle therapy with a basis in Western medical science from its traditional philosophical roots that happened to be in the East. Filshie and Cummings (1999) interpret ‘Western medical acupuncture’ as the scientific application of acupuncture as a therapy after orthodox clinical diagnosis. It is important to note that the scientific evaluation of acupuncture is not restricted to the West (Han & Terenius, 1982) and therefore adherence to a geographical definition is inappropriate. Probably a more accurate description of ‘Western medical acupuncture’ (WMA) is a modern scientific approach to therapy involving dry needling of tissues that has been developed from the introduction and evaluation of traditional Chinese acupuncture techniques in the West (Cummings, 2004). More recently the definition of WMA has been reconsidered and redefined (White, 2009): ‘Western medical acupuncture is a therapeutic modality involving the insertion of fine needles; it is an adaptation of Chinese acupuncture using current knowledge of anatomy, physiology, and pathology, and the principles of evidence based medicine’. Galileo established the modern scientific method in the 17th century when he introduced systematic verification through planned experiments to the existing ancient methods of reasoning and deduction (MacLachlan, 1999). This system was adopted by the scientific community throughout the globe, and, with the addition of statistical analysis, it remains established practice today. The ethical practice of medicine requires the practitioner to understand and use scientific method; however, there is great debate over the use of certain methods of testing efficacy when applied to potentially complex interventions such as acupuncture. The therapeutic effects of acupuncture needling are mediated through stimulation of the peripheral nervous system and so can be abolished by local anaesthetic (Chiang et al., 1973; Dundee & Ghaly, 1991). In particular, stimulation of Aδ or type III afferent nerve fibres has been implicated as the key component in producing analgesia (Chung et al., 1984). The therapeutic effects of needling can be divided into three categories based on the area influenced: local, segmental, and general. Local effects are mediated through antidromic stimulation of high threshold afferent nerves in the same way as the ‘triple response’ first described by Professor Sir Thomas Lewis (Lewis, 1927; Rous & Gilding, 1930). Release of trophic and vasoactive neuropeptides, including neuropeptide Y (NPY), calcitonin-gene-related-peptide (CGRP), and vasoactive-intestinal-peptide (VIP), has been demonstrated after acupuncture in patients with xerostomia (Dawidson et al., 1998a, 1998b). It is likely that the release of CGRP and VIP from peripheral nerves stimulated by needling results in enhanced circulation and wound healing in rats (Jansen et al., 1989a, 1989b); equivalent sensory stimulation has proved effective in human patients (Lundeberg et al., 1988). Increased circulation resulting from nerve stimulation is probably one of the most important local effects of acupuncture; in rats it appears to be principally mediated by the release of CGRP (Sato et al., 2000). The effect of acupuncture on muscle blood flow, however, may not rely solely on nerve stimulation (Shinbara et al., 2008). Under normal circumstances in healthy human subjects, blood flow in muscle and skin is increased by needling local muscle points and less affected by needling skin (Sandberg et al., 2003). But this situation may be reversed if the subject is very sensitive, for example, in patients with fibromyalgia (Sandberg et al., 2004). The increase in muscle and skin blood flow after local needling of muscle in patients with work-related trapezius myalgia appears to be lower than in healthy subjects, and this may reflect the degree of sympathetic activation and hypersensitivity of these patients (Sandberg et al., 2005). In 2010, Goldman and colleagues (2010) published a very detailed paper, including data from multiple experiments in rodent models of inflammatory and neuropathic pain, demonstrating a unilateral distal antinociceptive effect of acupuncture needling with manual stimulation via release of adenosine. Moré and colleagues (2013) went on to show that a similar antinociceptive effect could be abolished by high levels of caffeine consumption in a rodent model. Through stimulation of high threshold ergoreceptors in muscle, needling can have a profound influence on sensory modulation within the dorsal horn at the relevant segmental level. C fibre pain transmission is inhibited via enkephalinergic interneurons in lamina II, the substantia gelatinosa. Bowsher (1998) reviews the basic science literature, which supports this mechanism, and White (1999) appraises experimental and clinical evidence. Segmental stimulation appears to have a more powerful effect than an equivalent stimulus from a distant segment in modulating pain (Chapman et al., 1977; Lundeberg et al., 1989; Zhao, 2008), local autonomic activity (Sato et al., 1993), and itch (Lundeberg et al., 1987). Aδ or type III afferent nerve fibres can be stimulated by superficial needling as well as by needling deeper tissues, but it seems that segmental stimuli from the latter (usually muscle) have a more powerful effect (Lundeberg et al., 1987; Lundeberg et al., 1989; Ceccherelli et al., 1998; Zhao, 2008). When treating somatic pain, including muscle pain, in the clinical setting, it is difficult to differentiate between local and segmental effects of treatment because local needling can mediate both effects. Segmental effects are easier to illustrate when local needling is not possible, for example, in visceral complaints. Segmental electroacupuncture under the name percutaneous tibial nerve stimulation has been shown to affect bladder function in patients with overactive bladder symptoms (Van Balken et al., 2001, 2003; Macdiarmid et al., 2010; Peters et al., 2010). Visceral blood flow after acupuncture has also been studied. Although segmental effects appear to dominate (Stener-Victorin et al., 1996, 2003, 2004, 2006), nonsegmental mechanisms are also apparent (Uchida & Hotta, 2008). Although segmental stimulation appears to be the more powerful effect, needling anywhere in the body can influence afferent processing throughout the spinal cord. The needle stimulus travels from the segment of origin to the ventral posterior lateral nucleus of the thalamus and projects from there to the sensory cortex. Collaterals in the midbrain synapse in the periaqueductal grey (PAG), from where inhibitory fibres descend, via the nucleus raphe magnus, to influence afferent processing in the dorsal horn at every level of the spinal cord. Serotonin is the prominent neurotransmitter in the caudal stages of this descending pain pathway, and the fibres synapse with the enkephalinergic interneurons in lamina II. A second descending system from the PAG travels via the nucleus raphe gigantocellularis; its fibres are noradrenergic, and their influence is mediated directly on lamina II cells rather than via enkephalinergic interneurons. Diffuse noxious inhibitory control (DNIC) is the term introduced by Le Bars and colleagues to define a third analgaesic system, which is induced by a noxious stimulus anywhere in the body (Le Bars et al., 1979). Heterosegmental needling exerts influence through all three mechanisms to different degrees (Bowsher, 1998; White, 1999) and possibly through others as yet undefined. General effects are more difficult to define, and there is clearly some overlap with heterosegmental effects. The latter term is used here to denote effects mediated at every segment of the spinal cord, as opposed to effects mediated by humeral means or by influence on higher centres in the CNS controlling general responses. Acupuncture needling has proven efficacy in the treatment of nausea and vomiting (Vickers, 1996; Lee & Done, 2004; Lee & Fan, 2009), and this effect is likely to be mediated centrally. There is a substantial body of work that indicates the importance of β-endorphin and other endogenous opioids in acupuncture analgesia (Han & Terenius, 1982; Han, 2004, 2010; Zhao, 2008), and correlations have been identified between the endorphin releasing effect of acupuncture and that of prolonged exercise (Thoren et al., 1990). Further correlations in terms of neuropeptide release have been noted (Bucinskaite et al., 1996); it has also been suggested that chronic activation of opioid systems by exercise, or potentially by acupuncture, may mediate enhanced immunity, with decreased upper respiratory infections and protection against some forms of cancer (Jonsdottir, 1999). Functional magnetic resonance imaging (fMRI) studies indicate general effects on limbic structures (Hui et al., 2000) and indicate the importance of the nature of the needle stimulus in achieving this effect (Hui et al., 2007, 2009, 2010). Such effects may be important in pain as well as other conditions that affect general wellbeing. In 2014, a team led by Luis Ulloa from Rochester, New Jersey (Torres-Rosas et al., 2014), demonstrated a remarkable effect of 10 minutes stimulation of tibialis anterior with electroacupuncture in a rodent model of septic shock. This brief stimulation resulted in survival of the majority of animals, compared with 100% mortality in the controls. This effect was derived through stimulation of small afferent nerves in muscle, increased vagal tone, and dopamine release from the adrenal gland. Although target-directed expectation (Benedetti et al., 1999) may theoretically play a role in the mechanism of acupuncture under some circumstances, the effects of acupuncture do not appear to be explained entirely by expectation (Kong et al., 2009b, 2009a). In clinical practice, context driven effects are considered important (Finniss et al., 2010), but in this environment it is challenging to untangle the direct effects of acupuncture needling on central nervous system structures from the indirect effects related to the context of treatment. The mechanism of action of direct needling in the deactivation of trigger points is undetermined. Despite the fact that a causal relationship has not been established between direct needling of trigger points and improvement in symptoms, a discussion of the potential mechanisms involved may still be useful in developing future research questions. Simons and colleagues (1999) commented on the results of two trials that compare direct dry and direct wet needling of trigger points (Skootsky et al., 1989; Hong, 1994) and conclude that the critical therapeutic factor in both techniques is mechanical disruption by the needle. The common factor is certainly needle insertion into the trigger point; however, Hong (1994) highlighted the importance of stimulating a local twitch response in achieving an immediate effect and, with Simons, cites evidence that the local twitch response is mediated by a segmental spinal reflex (Hong & Simons, 1998). Fine and colleagues (1988) performed a rigorous experimental study in which trigger points were subject to direct wet needling and clearly demonstrated that an opioid mechanism was involved in trigger point pain relief. In light of this evidence it seems likely that the needle works more often through sensory stimulation than through mechanical disruption; this would be consistent with the mechanism of action of acupuncture analgesia (Han & Terenius, 1982; Han, 2004; Zhao, 2008; Han 2010). Having said that, techniques vary considerably, and it is possible that the more vigorous and fast insertion trigger point needling has a direct mechanical effect on endplates, muscle spindles, or fibres themselves. Readers are referred to Chapter 2 of the current textbook for physiological mechanisms of trigger point dry needling. The principal methodological difficulties in clinical trials that study the efficacy of acupuncture are concerned with controls and blinding (Lewith & Vincent, 1998; White et al., 2001b; Cummings & White, 2016). For a placebo control to be credible the subjects receiving it must believe that they have had an active treatment, identical to, or at least equivalent in potency to, the active intervention. Ideally, for any needling therapy the control should involve an inactive form of needling, but it seems clear that a needle placed anywhere in the body is likely to have some neurophysiological effect (Lewith & Machin, 1983)—perhaps as a result of the noxious stimulus (Le Bars et al., 1979) of a needle piercing skin, or perhaps related to context-driven and interactional effects including target-directed expectation (Benedetti et al., 1999) and complex conditioned responses (Lundeberg & Lund, 2008). An innovation in needle design (Streitberger & Kleinhenz, 1998; Kleinhenz et al., 1999) appeared at first to overcome the problem of needle penetration of skin by using a blunt needle that slid up into the coiled metal of the handle. This device was credible to the subject, but in order to simulate needle retention in the body, it needed to be attached to the skin. This was done by inserting it through an adhesive plaster dressing over a small plastic ring placed over the point. In practice, however, the blunt needles pushed with enough force to get through the plaster and also occasionally penetrated the skin surface (Konrad Streitberger: personal communication, 2001). The Park sham device, which consists of a plastic guide tube of adjustable height with a sticky base, was developed as an alternative method of holding the sham needle in place (Park et al., 2002); however, the subject could be unmasked if a needle fell out of the device. A convincing control procedure should result in blinding of the subject, but it is almost impossible to blind an experienced therapist who is performing both real and sham needling techniques. A common way of reducing bias in this situation is to use a blind assessor. A nonpenetrating needle device that blinds the practitioner as well as the subject has been developed and validated (Takakura & Yajima, 2007, 2008). However, it seems that simple nonpenetrating sham acupuncture procedures such as blunted cocktail sticks tapped on the skin can be highly effective in clinical trials (Cherkin et al., 2009), and so the measured efficacy of true acupuncture over sham techniques in clinical trials is often small and not statistically significant. A Cochrane review on acupuncture and dry needling for low back pain, which included 35 RCTs, concluded that (Furlan et al., 2005) ‘for chronic low back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short term only’. A systematic review published in the same year also found acupuncture to be significantly more effective than sham acupuncture in chronic low back pain (Manheimer et al., 2005). More recent systematic reviews have not included meta-analysis. The Cochrane review (including meta-analysis) is being updated and the pooled results are not expected to change substantially (Andrea Furlan: personal communication, 2010). In the UK, 2009 guidelines from the National Institute for Health and Clinical Excellence (NICE, 2009) for early management of persistent nonspecific low back pain between 6 months and 1 year included consideration of 12 sessions of acupuncture over 3 months. This recommendation was overturned in a subsequent guideline (NICE, 2016), which caused considerable controversy, as the evidence for acupuncture appeared to exceed that of more conventional interventions that were recommended in NG59. The most robust statistical data comes from the Acupuncture Trialists Collaboration (ATC) lead by Andrew Vickers (Vickers et al., 2012). They performed an individual patient data (IPD) meta-analysis with data from the highest quality RCTs of acupuncture in chronic pain conditions (19 trials, 17,922 patients). Highly statistically significant benefits were measured over sham and usual care controls, but the effect size over sham was small. Subsequent network meta-analysis with the same data indicates that sham acupuncture has clear benefits over usual care controls in terms of health-related quality of life, suggesting real effects of sham acupuncture, which is already recognised to be superior to most other placebo controls (Meissner et al., 2013). The first Cochrane review on acupuncture for idiopathic chronic headache was tentatively positive (Melchart et al., 2001) but criticised for including trials on both migraine prophylaxis and chronic tension type headache. In 2009 the Cochrane review was updated and split into acupuncture for migraine prophylaxis (Linde et al., 2009a) and acupuncture for tension-type headache (Linde et al., 2009b). The latter recorded an effect of acupuncture over sham. This was not the case for migraine prophylaxis; however, acupuncture was marginally superior to drug prophylaxis. In the 2016 update of the reviews with more data (including IPD summary figures from Vickers et al., 2012), acupuncture proved to be marginally superior to sham as well as drug prophylaxis in migraine (Linde et al., 2016a), and it continued to be superior to sham in tension-type headache (Linde et al., 2016b). NICE (2012) did recommend acupuncture, but concluded that the drug topiramate was twice as good from a very limited network meta-analysis (NMA). This is explained by the exclusion of data from direct comparisons between acupuncture and drug prophylaxis, along with the large differences in responder rates to sham acupuncture compared with drug placebos (White & Cummings, 2012). A systematic review included 13 RCTs (White et al., 2007). The results from the five high quality trials (n = 1334) were pooled in meta-analysis for the primary outcome and demonstrated a significant effect of acupuncture versus sham in short term pain. A subsequent review by Manheimer and colleagues found very similar results in their meta-analysis (Manheimer et al., 2007), although their interpretation of the clinical relevance of the results differed entirely. The recent Cochrane review of acupuncture for peripheral joint osteoarthritis (OA) (Manheimer et al., 2010) included 16 trials and 3498 participants. Twelve trials were on OA knee, three on OA hip, and one included both. The authors concluded: ‘Sham-controlled trials show statistically significant benefits; however, these benefits are small, do not meet our predefined thresholds for clinical relevance, and are probably due at least partially to placebo effects from incomplete blinding. Waiting list-controlled trials of acupuncture for peripheral joint osteoarthritis suggest statistically significant and clinically relevant benefits, much of which may be due to expectation or placebo effects.’ White and Cummings (2009) argue that you only test the biological plausibility of acupuncture against sham acupuncture, not its clinical relevance. The IPD meta-analysis by Vickers and colleagues (2012) confirms a clear statistical benefit of acupuncture over sham and a clinically relevant benefit over usual care controls. Despite this and an NMA suggesting that acupuncture is one of the best nonpharmacological therapies (Corbett et al., 2013), it has not been recommended for osteoarthritis by NICE in the UK (NICE, 2014). The Cochrane review on acupuncture for shoulder pain in 2005 was inconclusive but suggested that there may be a short-term benefit on pain and function (Green et al., 2005). Since then there have been two interesting trials. Vas and colleagues (2008) demonstrated the advantage of manual acupuncture to a single point (ST38) versus sham (mock TENS) along with physical therapy rehabilitation for shoulder pain in 425 subjects. The GRASP trial (German Randomised Acupuncture trial for chronic Shoulder Pain) tested acupuncture against a distant superficial off-point sham and conventional orthopaedic care in 424 subjects with chronic shoulder pain (Molsberger et al., 2010). Acupuncture proved to be superior to sham and conventional orthopaedic care, although the dropout rate in the sham group was rather high at 45%. Similar to the other pain categories discussed previously, the IPD meta-analysis by Vickers and colleagues (2012) confirms a clear statistical benefit of acupuncture over sham, but unlike spinal pain (back & neck pain data combined), osteoarthritis, and headache, the effect size over sham exceeded what would be considered by NICE to be a minimal important clinical difference. A systematic review published in 2001 of 23 randomised controlled trials conclusively shows that, when treating myofascial pain with trigger point injection, the nature of the injected substance makes no difference to the outcome and that there is no therapeutic benefit in wet over dry needling (Cummings & White, 2001). These conclusions were supported by all the high quality trials in the review. The review did not find any rigorous evidence that needling therapies have a specific effect in myofascial pain, as authors Cummings and White (2001) concluded: ‘The hypothesis that needling therapies have specific efficacy in the treatment of myofascial pain is not supported by the research to date, but this review suggests that any effect derived from these therapies is likely to be derived from the needle, rather than from either, an injection of liquid in general, or any substance in particular. All groups in the review in whom trigger points were directly needled showed marked improvement in their symptoms; therefore further research is urgently needed to establish the specific effect of trigger point needling, with emphasis on the use of an adequate control for the needle’. This review has not been formally updated, but from the author’s knowledge of the literature published since 2001, there would be no substantial change to the conclusions. A further review with meta-analysis including only trials of dry needling was inconclusive, although the results were compatible with a treatment effect of dry needling on myofascial trigger point pain (Tough et al., 2009). Another review including meta-analysis with an anatomically limited focus (upper quadrant) was positive for dry needling (Kietrys et al., 2013). Acupuncture involves the insertion of needles (usually stainless steel) into the body. Although it is often perceived by the general public as ‘natural’ and ‘safe’, along with many complementary therapies, it is neither natural nor completely safe. As with any needling therapy, the serious risks are associated with the transmission of blood-borne infection and direct trauma. Rampes and Peuker categorise adverse events associated with acupuncture as follows (Rampes & Peuker, 1999): If acupuncture is performed as a therapy by a regulated healthcare professional within his or her sphere of competence, the first two categories will be avoided. Persistent pain attributed to acupuncture treatment is rare, but temporary exacerbation of the presenting complaint for a day or so is common (MacPherson et al., 2001a, 2001b; White et al., 2001a). Pain lasting up to 180 days after needling has been reported in a prospective study of over 2 million treatment sessions, apparently due to nerve damage (Witt et al., 2009). The author has heard verbal reports of persistent neuropathic pain around needle insertion points after acupuncture; however, these events are likely to be very rare because filiform acupuncture needles do not have a cutting edge. Although in the past nerves were directly targeted at some acupuncture points, contemporary practice in the West tends to avoid direct needling of nerves (White et al., 2008b). Autonomic reactions include syncope and sedation. Syncope can be largely avoided by treating patients while lying on an examination couch; however, very occasionally a profound sinus bradycardia will result in loss of consciousness of a patient who is lying down. Sedation is relatively common and occurs in perhaps 20% of patients after their first two treatments. In maybe 5% of patients there is always some degree of sedation associated with acupuncture treatment. Sedation is rarely seen as adverse event by the patients and is only of concern in terms of driving home or operating machinery after treatment. Infections associated with acupuncture treatment are rare but can be serious (White, 2004). Worldwide, hepatitis B would be the most common infection related to acupuncture, but this is now very rare in the West as a result of the use of sterile disposable needles and clean techniques. Traumatic complications of acupuncture needling are avoidable, but on occasion they have been fatal. The most frequent of the serious traumatic adverse effects is pneumothorax, which is estimated (from prospective studies) to occur between 1:200,000 (White, 2004) and 1:1 million (Witt et al., 2009) treatment sessions. The drawback with these estimates is that they include all acupuncture session, not just those in which there has been needling over the thorax. The two main themes in Western medical acupuncture are dry needling of trigger points and segmental acupuncture (Cummings, 2016). The latter is defined as the technique of needling an area of the soma innervated by the same spinal segment as the disordered structure under treatment (Filshie & Cummings, 1999). Based on neurophysiological and clinical evidence (Chapman et al., 1977; Lundeberg et al., 1987, 1989; Sato et al., 1993; Bowsher, 1998; Ceccherelli et al., 1998; White, 1999), the main principle in point selection is to stimulate the soma as close as is practical to the seat of the pathology or at least within the same segment. Local trigger points, tender points, or acupuncture points are chosen, and often these will overlap so that the key point to stimulate is a trigger point, which is tender by definition, at the site of an acupuncture point. The figures in this chapter illustrate commonly used acupuncture points and trigger points represented by body region (Figs. 14.1–14.10 and Tables 14.1–14.5). If the key element of the somatic pathology is a myofascial trigger point, this is arguably the only point that it is necessary to treat. In most other cases the analgesia afforded by local needling may be enhanced by using one or more points at a distance from the pathology in addition to the relevant local points. Distant points are chosen because they stimulate the appropriate segment or because they are conveniently located and known to generate strong needling sensation (heterosegmental acupuncture). In individual cases, point selection may be modified by the need to avoid local conditions (e.g., skin infection, ulceration, moles and tumours, varicosities) or to avoid regional conditions such as hydrostatic oedema, lymphedema, anaesthetic or hyperaesthetic areas, or ischaemia. As a general rule, therapeutic needling should be performed in healthy tissue. Table 14.1
Dry Needling from a Western Medical Acupuncture Perspective
Introduction and historical development
Dry Needling—A Historical Perspective
Traditional Acupuncture
Western Medical Acupuncture
Neurophysiological mechanisms of the technique
Neurophysiology of Acupuncture Needling
Local effects
Segmental effects
Heterosegmental effects
General effects
Trigger Point Needling
Clinical research
Methodological Difficulties of Clinical Acupuncture Research
Evidence for Acupuncture Needling in Chronic Pain Conditions
Chronic low back pain
Chronic headache
Osteoarthritis
Shoulder pain
Evidence for Needling in Myofascial Pain
Clinical application of the technique
Safety Aspects
Point Selection
Face
Yintang
Midpoint between the eyebrows
D Vi
M VII
S Vi
Angulation: oblique inferior
Target: procerus or periosteum
Headache, hayfever, relaxation
Taiyang
1 cun posterior to the midpoint between the lateral end of the eyebrow and the lateral canthus of the eye
D Vii
M Viii
S Vii
Angulation: perpendicular
Target: temporalis
Headache, eye symptoms
GB14
1 cun above the middle of the eyebrow, directly above the pupil when the eyes are looking straight ahead
D Vi
M VII
S Vi
Angulation: oblique inferio
Target: frontalis
Headache, eye symptoms
LI 20
In the nasolabial groove, level with the widest part of the ala nasi
D Vii
M VII
S Vii
Angulation: superiorly along groove
Target: facial muscles
Hayfever, nasal symptoms
ST6
1 fingerbreadth anterior and superior to the angle of the jaw, on the prominence of masseter
D C2/C3
M Viii
S Viii
Angulation: perpendicular
Target: masseter
Dental pain, facial pain
ST7
In the depression anterior to the temporomandibular joint and below the zygomatic arch
D Viii
M Viii
S Viii
Angulation: perpendicular
Target: lateral pterygoid
Dental pain, facial pain
ST8
0.5 cun superior to the upper line of origin of the temporalis muscle, directly above ST7 and ST6 on a vertical line 0.5 cun posterior to Taiyang
D Vi/Vii
M Viii/VIIS Vi/Vii
Angulation: perpendicular
Target: epicranial tissues
Headache
SI18
Directly below the lateral canthus of the eye in the depression at the lower border of the zygomatic bone, just anterior to the attachment of masseter
D Vii
M Viii/S Vii
Angulation: slightly superior
Target: connective tissue space
Facial pain, trigeminal neuralgia
LI18
Between the sternal and clavicular heads of sternocleidomastoid (SCM), level with the laryngeal prominence (the tip of the Adam’s apple)
D C2/C3
M XI/C2/C3
S n/a
Angulation: posterior
Target: fascial plane in SCM
Pain from sternocleidomastoid—headache or facial pain
CAUTION: note the proximity of the carotid artery
Head and Neck
GB20
Below the occipital bone, in the depression between trapezius and sternocleidomastoid and above splenius capitis
D C2/C3
M C1/C2
S C1/C2
Angulation: towards opposite eyebrow
Target: semispinalis capitis
Headache, neck pain, and stiffness
CAUTION: note the position of the vertebral artery
Head and Neck
BL10
1.3 cun lateral to the spinous process of C2, between C1 and C2
D C3
M C1 to C5
S C2/C3
Angulation: towards lamina of C2
Target: obliquus inferior
Neck pain and stiffness
CAUTION: note the position and depth of the spinal cord and vertebral artery
GB21
Midway between GV14 and tip of the acromion at the highest point of trapezius
D C3
M C3/C4S n/a
Angulation: tangential to ribs, posteriorly
Target: upper trapezius
Headache, neck pain and stiffness, anxiety
CAUTION: note the proximity of the pleura between the 1st and 2nd ribs
TE15
Midway between the points GB21 and SI13 at the superior angle of the Scapula (SI13—tender depression superior to medial end of scapular spine)
D C3
M C3/C4
S n/a
Angulation: perpendicular
Target: trapezius
Shoulder pain, neck pain and stiffness
CAUTION: note the proximity of the pleura in slim patients
GV14
Between spinous processes C7 and T1
D C4/C5/T1
M C8S C8
Angulation: transverse
Target: interspinous ligament
Spinal neck pain, headache of cervical origin
SI14
3 cun lateral to spinous process of T1
D C3/C4 M C3/C4/C5
S C5
Angulation: tangential towards scapula
Target: levator scapulae
Shoulder pain, neck pain and stiffness
CAUTION: do not needle deeply unless confident of angulation relative to scapula
BL11
1.5 cun lateral to the lower border of the spinous process of T1
D C4/T1
M C4/C5
S T1/T2
Angulation: oblique towards spine
Target: rhomboid minor
Neck pain and stiffness, dyspnoea
CAUTION: do not needle deeply unless confident of angulation relative to pleura
BL45
3 cun lateral to the lower border of the spinous process of T6
D T5/T6
M T6/T7
S T6/T7
Angulation: oblique towards spine
Target: iliocostalis thoracis
Dorsal back pain, dyspnoea
CAUTION: do not needle deeply unless confident of angulation relative to pleura
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