New findings of the correlation between acupoints and corresponding brain cortices using functional MRI

Using microPET imaging in quantitative verification of the acupuncture effect in ischemia stroke treatment

Acupuncture has been indispensable in Chinese medicine. However, its function still remains elusive. This paper studies the effect of acupuncture in ischemia stroke treatment using the Sprague Dawley rat animal model. We induced focal cerebral ischemia in rats using the middle cerebral artery occlusion (MCAO) procedure. For each rat in the real acupuncture group (n = 63), the sham acupoint treatment group (n = 62), and the blank control group (n = 30), we acquired 3-D fluorodeoxyglucose-microPET images at baseline, after MCAO, and after treatment, respectively. Then, we measured the changes of the injury-volume in the right hemisphere of these rats. The measurements showed that real acupuncture slightly reduced the injury-volume, sham acupoint treatment increased the injury-volume, and blank control had no obvious effect in reducing the injury-volume. Statistical tests also confirmed that acupuncture was more effective than random stimulus in improving the metabolic recovery after stroke.

Acupuncture induces divergent alterations of functional connectivity within conventional frequency bands: evidence from MEG recordings

As an ancient Chinese healing modality which has gained increasing popularity in modern society, acupuncture involves stimulation with fine needles inserted into acupoints. Both traditional literature and clinical data indicated that modulation effects largely depend on specific designated acupoints. However, scientific representations of acupoint specificity remain controversial. In the present study, considering the new findings on the sustained effects of acupuncture and its time-varied temporal characteristics, we employed an electrophysiological imaging modality namely magnetoencephalography with a temporal resolution on the order of milliseconds. Taken into account the differential band-limited signal modulations induced by acupuncture, we sought to explore whether or not stimulation at Stomach Meridian 36 (ST36) and a nearby non-meridian point (NAP) would evoke divergent functional connectivity alterations within delta, theta, alpha, beta and gamma bands. Whole-head scanning was performed on 28 healthy participants during an eyes-closed no-task condition both preceding and following acupuncture. Data analysis involved calculation of band-limited power (BLP) followed by pair-wise BLP correlations. Further averaging was conducted to obtain local and remote connectivity. Statistical analyses revealed the increased connection degree of the left temporal cortex within delta (0.5-4 Hz), beta (13-30 Hz) and gamma (30-48 Hz) bands following verum acupuncture. Moreover, we not only validated the closer linkage of the left temporal cortex with the prefrontal and frontal cortices, but further pinpointed that such patterns were more extensively distributed in the ST36 group in the delta and beta bands compared to the restriction only to the delta band for NAP. Psychophysical results for significant pain threshold elevation further confirmed the analgesic effect of acupuncture at ST36. In conclusion, our findings may provide a new perspective to lend support for the specificity of neural expression underlying acupuncture.

Correlating acupuncture FMRI in the human brainstem with heart rate variability

Past neuroimaging studies of acupuncture have demonstrated variable results for important brainstem nuclei. We have employed cardiac-gated fMRI with T1-variability correction to study the processing of acupuncture by the human brain. Furthermore, our imaging experiments collected simultaneous ECG data in order to correlate heart rate variability (HRV) with fMRI signal intensity. Subjects experienced one of three stimulations over a 31.5 minute fMRI run: (1) electro-acupuncture at 2Hz/15Hz over the acupoint ST-36 (2) electro-acupuncture at a sham non-acupoint, or (3) sensory control tapping over ST-36. The ECG was analyzed with power spectral methods for low frequency and high frequency components, which reflect the balance in the autonomic nervous system. The HRV data was then correlated with the time-varying fMRI signal intensity. Our data suggests that fMRI activity in the hypothalamus, the dorsal raphe nucleus, the periaqueductal gray, and the rostroventral medulla showed significant correlation with LF/HF ratio calculated from simultaneous HRV data. The correlation of time-varying fMRI response with physiological parameters may provide insight into connections between acupuncture modulation of the autonomic nervous system and neuroprocessing.

A PET-CT study on the specificity of acupoints through acupuncture treatment in migraine patients

Background

In the field of acupuncture research, the topic of acupoint specificity has received increasing attention, but no unified conclusion has been reached on whether or not acupoint specificity exists. Furthermore, the majority of previous acupuncture neuroimaging studies have been performed using healthy subjects. In this study, patients with migraine were used to investigate acupoint specificity.

Methods

Thirty patients with migraine were enrolled and randomized into three groups: Traditional Acupuncture Group (TAG), Control Acupuncture Group (CAG), and Migraine Group (MG). The TAG was treated by acupuncture stimulation at Waiguan (TE5), Yang Lingquan (GB34), and Fengchi (GB20). The CAG was treated at Touwei (ST8), Pianli (LI6), and Zusanli (ST36). The MG received no treatment. Positron emission tomography with computed tomography (PET-CT) was used to test for differences in brain activation between the TAG and CAG versus MG, respectively.

Results

Traditional acupuncture treatment was more effective for pain reduction than control acupuncture treatment. The TAG showed higher brain metabolism than the MG in the middle temporal cortex (MTC), orbital frontal cortex (OFC), insula, middle frontal gyrus, angular gyrus, post-cingulate cortex (PCC), the precuneus, and the middle cingulate cortex (MCC). Metabolism decreased in the parahippocampus, hippocampus, fusiform gyrus, postcentral gyrus, and cerebellum in the TAG compared with the MG. In the CAG, metabolism increased compared with the MG in the MTC, supratemporal gyrus, supramarginal gyrus, and MCC, whereas metabolism decreased in the cerebellum.

Conclusions

Acupuncture stimulation of different points on similar body regions in migraine patients reduced pain and induced different levels of cerebral glucose metabolism in pain-related brain regions. These findings may support the functional specificity of migraine- treatment-related acupoint.

Trial registration

The number of our clinical trial registration is: ChiCTR-TRC-11001813, and the protocol and inclusion criteria have already been registered as ChiCTR-TRC-11001813.

Differential neural responses to acupuncture revealed by MEG using wavelet-based time-frequency analysis: a pilot study

Acupoint specificity, lying at the core of the Traditional Chinese Medicine, still faces many controversies. As previous neuroimaging studies on acupuncture mainly adopted relatively low time-resolution functional magnetic resonance imaging (fMRI) technology and inappropriate block-designed experimental paradigm due to sustained effect, in the current study, we employed a single block-designed paradigm together with high temporal-resolution magnetoencephalography (MEG) technology. We applied time-frequency analysis based upon Morlet wavelet transforming approach to detect differential oscillatory brain dynamics induced by acupuncture at Stomach Meridian 36 (ST36) using a nearby nonacupoint (NAP) as control condition. We observed that frequency power changes were mainly restricted to delta band for both ST36 group and NAP group. Consistently increased delta band power in contralateral temporal regions and decreased power in the counterparts of ipsilateral hemisphere were detected following stimulation at ST36 on the right leg. Compared with ST36, no significant delta ranges were found in temporal regions in NAP group, illustrating different oscillatory brain patterns. Our results may provide additional evidence to support the specificity of acupuncture modulation effects.

Capturing amplitude changes of low-frequency fluctuations in functional magnetic resonance imaging signal: a pilot acupuncture study on NeiGuan (PC6)

OBJECTIVES

This study aims to examine amplitude changes of low-frequency oscillations (fALFF) in the blood-oxygen level-dependent (BOLD) signal associated with acupuncture on NeiGuan (PC6).

EXPERIMENTAL DESIGN

Ten (10) healthy adults participated in a functional magnetic resonance imaging (i.e., nuclear medicine; fMRI) study. During the brain-imaging procedure, the participants were instructed to lie quietly; they did not perform any cognitive task.

MAIN OUTCOME MEASURES

Three (3) fMRI scans were conducted for each participant: a first resting-state scan (R1), a stimulating-acupoint scan (AP), and a second resting-state scan (R2) after AP. Individual fALFF maps were calculated for each scan.

RESULTS

During R1, consistent with previous studies, the default network regions showed significantly detectable fALFF amplitudes. Acupuncture on PC6 increased fALFF amplitudes within the anterior cingulate cortex (ACC), occipital fusiform gyrus, posterior cingulate cortex, and precuneus (PCC/PCU). In contrast, during R2, fALFF within PCC is still significantly higher than R1 while ACC and cerebellum showed decreased fALFF.

CONCLUSIONS

These findings imply that stimulating PC6 can change the amplitude of the intrinsic cortical activity of the brain. In particular, a continuous and temporally consistent effect of acupuncture within PCC not the common brain circuit of pain including ACC and cerebellum was observed. Considering the cognitive functions and deficits of the relevant areas in mild cognitive impairment and Alzheimer disease, acupuncture on PC6 could potentially affect both psychiatric and neurological disorders. Thus, stimulating PC6 may be a candidate method for improving cognitive impairment.

Altered small-world efficiency of brain functional networks in acupuncture at ST36: a functional MRI study

Background

Acupuncture in humans can produce clinical effects via the central nervous system. However, the neural substrates of acupuncture’s effects remain largely unknown.

Results

We utilized functional MRI to investigate the topological efficiency of brain functional networks in eighteen healthy young adults who were scanned before and after acupuncture at the ST36 acupoints (ACUP) and its sham point (SHAM). Whole-brain functional networks were constructed by thresholding temporal correlations matrices of ninety brain regions, followed by a graph theory-based analysis. We showed that brain functional networks exhibited small-world attributes (high local and global efficiency) regardless of the order of acupuncture and stimulus points, a finding compatible with previous studies of brain functional networks. Furthermore, the brain networks had increased local efficiency after ACUP stimulation but there were no significant differences after SHAM, indicating a specificity of acupuncture point in coordinating local information flow over the whole brain. Moreover, significant (P<0.05, corrected by false discovery rate approach) effects of only acupuncture point were detected on nodal degree of the left hippocampus (higher nodal degree at ACUP as compared to SHAM). Using an uncorrected P<0.05, point-related effects were also observed in the anterior cingulate cortex, frontal and occipital regions while stimulation-related effects in various brain regions of frontal, parietal and occipital cortex regions. In addition, we found that several limbic and subcortical brain regions exhibited point- and stimulation-related alterations in their regional homogeneity (P<0.05, uncorrected).

Conclusions

Our results suggest that acupuncture modulates topological organization of whole-brain functional brain networks and the modulation has point specificity. These findings provide new insights into neuronal mechanism of acupuncture from the perspective of functional integration. Further studies would be interesting to apply network analysis approaches to study the effects of acupuncture treatments on brain disorders.

Integrative laser medicine and high-tech acupuncture at the medical university of graz, austria, europe

At the moment, modernization of acupuncture has a high priority. On the traditional side, acupuncture has only recently been awarded the status of Intangible Cultural Heritage by the UNESCO. On the innovative side, high-tech acupuncture is a registered trademark in Austria. Acupuncture has been used for medical treatment for thousands of years. A large number of empirical data are available but the technical quantification of effects was not possible up to now. Using electroacupuncture, needle, or laser stimulation and modern biomedical techniques, it was possible for the first time to quantify changes in biological activities caused by acupuncture. This paper which serves as introduction for the special issue “High-Tech Acupuncture and Integrative Laser Medicine” of the present journal, focuses on the latest innovative aspects that underline the further enhancement and development of acupuncture. Special emphasis is given to new methodological and technical investigations, for example, results obtained from all kinds of acupuncture innovations (e.g., teleacupuncture) and integrative laser medicine.

A review of Omics research in acupuncture: the relevance and future prospects for understanding the nature of meridians and acupoints

RELEVANCE

Acupuncture is an intrinsic part of traditional Chinese medicine. The current understanding of the acupuncture meridian system, acupoints and the potential utilizing Omics technologies are summarized in this review.

MATERIAL AND METHODS

A systematic search for acupuncture involving Omics technologies was carried out using multiple online literature databases. The records retrieved were from the full collections of each database dated to September 2011. Data produced from functional genomic technologies were extracted from the collected acupuncture/moxibustion studies and subjected to evaluation. Analyses and comments were summarized on the advances in experimental research in acupuncture/moxibustion-related studies, and the future for strategies and approaches in the era of functional genomics highlighted.

RESULTS

An overview of articles indicated that several diseases or symptoms with evidence of effectiveness had been piloted for using functional genomic technologies, such as Parkinson's disease, allergic disorders, pain, and spinal cord injury, most of which are chronic "difficult diseases". High-throughput genomic and proteomic profiling of gene expression in tissues has been able to identify potential candidates for the effects of acupuncture and provide valuable information toward understanding the possible mechanisms of the therapy. However, without further holistic and sophisticated analyses in the context of metabolomics and systems biology, the current attempts and the foreseeable developments appear to be insufficient to produce firm conclusions. Noticeably, the recent rapid advances in functional molecular imaging targeting specific metabolites have shown great promise and if combined with other post-genomic technologies, could be extremely helpful for the acupuncture studies in human subjects.

CONCLUSION

This review suggest that disease-oriented studies using the approach of multi-indexed high-throughput technologies and systems biology analyses will be a preferred strategy for future acupuncture/moxibustion research.

Acupuncture Stimulation at Sanyinjiao: Effect on the Sodium Pertechnetate Bioavailability in Rats

In clinical acupuncture, when acupuncture points are stimulated, several types of reflex responses can be evoked. Consequently, different categories of physiological responses are induced, which include changes in the activities of internal organs and tissues. The acupuncture point Sanyinjiao (SP6) has been used successfully to treat different human gastrointestinal conditions. The aim of this work was to investigate the effects of end-organ response induced by acupuncture point SP6 on the bioavailability of the radiopharmaceutical sodium pertechnetate ( Na 99 m TcO 4) in Wistar rats. Healthy rats were allocated into 2 groups, control-CG and treated-TG. TG was bilaterally stimulated at acupuncture point SP6 with stainless steel needles. Ocular plexus administration of Na 99 m TcO 4 (3.7MBq) was carried out 10 min after every needle insertion in all animals. Ten minutes later, the animals were killed, the organs were isolated, the radioactivity was determined in a well gamma counter, and the percentage of injected dose per gram of tissue (%ID/g) was determined for each organ. The %ID/g was significantly altered ( p < 0.05) in the small intestine of TG (0.56 ± 0.09) when compared to CG (0.82 ± 0.18). These results may suggest that this stimulation might induce physiological responses capable of altering the bioavailability of the radiopharmaceutical sodium pertechnetate. These findings aid in providing a better understanding of acupuncture and its effects on various organs and tissues.

Effects of Electroacupuncture at BL60 on Formalin-Induced Pain in Rats

Acupuncture was used to treat symptoms of pain in the ancient orient. The present study was conducted to determine the effects of electroacupuncture (EA) at the BL60 acupoint on male Sprague-Dawley rats. Each rat received EA at BL60 acupoint before formalin injection. Behavioral responses were recorded using a video camera and c-Fos immunohistochemistry was performed thereafter. Treatment of EA at BL60 significantly inhibited flinching behavior and c-fos expression induced by formalin injection into the paw, compared to a control group. These results suggest that electroacupuncture at BL60 acupoint may be effective in relieving inflammatory pain.

The Effect of Acupuncture at PC-6 on the Electroencephalogram and Electrocardiogram

The present study aims to examine the effect of acupuncture stimulation of an acupuncture point (PC-6) and nonacupuncture point on electroencephalograms (EEGs) and electrocardiograms (ECGs). We used EEG in 10 healthy subjects to investigate cortical activation during stimulation of acupuncture points (neiguan: PC-6) and nonacupuncture points. Our most interesting finding was the marked differences of amplitude of EEG power between acupuncture points and nonacupuncture points stimulation. Wavelet transform was used as the EEG signal processing method, because it has advantages in a time domain and frequency domain characteristics analysis. EEGs were collected from 16 channels, and the α-wave (8–13 Hz), β-wave (13–30 Hz), θ-wave (4–8 Hz) and δ-wave (0.5–4 Hz) were used as standards for frequency bands. According to the experiment results, EEG signals increased considerably after acupuncture stimulation; in each frequency band, the average amplitude was higher after acupuncture stimulation; ECG heart rates were faster by at least 10% after acupuncture stimulation. Consequently, it will be possible to verify the function of acupuncture stimulation on neiguan (acupuncture points; PC-6) more effectively.

Quantification of Electroacupuncture-Induced Neural Activity by Analysis of Functional Neural Imaging with Monocrystalline Iron Oxide Nanocolloid Enhancement

The purpose of this study was to investigate the neural activity of electroacupuncture (EA) quantitatively. The responses of Sprague–Dawley rats' brain to EA on acupoints — Hegu (LI 4) and Neiguan (PC 6) — were detected by monocrystalline iron oxide nanoparticle (MION)-enhanced functional magnetic resonance imaging (MION-fMRI), which is a 1.5 T horizontal spectrometer equipped with a circular polarized extremity coil. During EA at LI 4, neural activities were analyzed by analysis of functional neural images (AFNI). Neural activation was detected at the structures of hypothalamus, thalamus, hippocampus, and the cortex, while neural deactivation existed at the areas adjacent to the activated sites. EA on PC 6 activated the structures of thalamus and the cortex but deactivated the structures of hypothalamus and hippocampus. The brain responses to EA existed in different areas of activation and deactivation despite stimulating the same acupoint. Additionally, distinct brain neuroimages were produced through stimulating different acupoints. This study suggests that fMRI with AFNI is a good approach to quantifying brain activities. This innovative method brings new perspective into the mechanisms of acupuncture.

Acupuncture Stimulation for Motor Cortex Activities: A 3T fMRI Study

The acupoint, GB34, located in the back of the knee, is known to be effective in recovering motor function after a stroke. This study uses a functional magnetic resonance imaging (fMRI) study with 3T scanner to investigate whether or not acupuncture of GB34 produces a significant response of the modulation of somatomotor areas. A fMRI of the whole brain was performed in ten normal healthy subjects during two task stimulations of acupuncture manipulation on GB34 and sham points, inserting and twisting the needle for 25 seconds at a rate of approximately 120 times per minute; the needle manipulation was paused for a duration of 25 seconds as a control state. The process was repeated four times to have four epochs of stimulation. Bilateral sensorimotor areas (BA 3, 4, 6 and 7) showed approximately 6% of stimulation-related BOLD signal contrast, whereas very few areas were activated when sham stimulation was given. Acupuncture stimulation in GB34 modulates the cortical activities of the somatomotor area in humans. The present findings may shed light on the CNS mechanism of motor function by acupuncture, and form a basis for future investigations of motor modulation circuits in stroke patients.

Neural acupuncture unit: a new concept for interpreting effects and mechanisms of acupuncture

When an acupuncture needle is inserted into a designated point on the body and mechanical or electrical stimulation is delivered, various neural and neuroactive components are activated. The collection of the activated neural and neuroactive components distributed in the skin, muscle, and connective tissues surrounding the inserted needle is defined as a neural acupuncture unit (NAU). The traditionally defined acupoints represent an anatomical landmark system that indicates local sites where NAUs may contain relatively dense and concentrated neural and neuroactive components, upon which acupuncture stimulation would elicit a more efficient therapeutic response. The NAU-based local mechanisms of biochemical and biophysical reactions play an important role in acupuncture-induced analgesia. Different properties of NAUs are associated with different components of needling sensation. There exist several central pathways to convey NAU-induced acupuncture signals, Electroacupuncture (EA) frequency-specific neurochemical effects are related to different peripheral and central pathways transmitting afferent signals from different frequency of NAU stimulation. More widespread and intense neuroimaging responses of brain regions to acupuncture may be a consequence of more efficient NAU stimulation modes. The introduction of the conception of NAU provides a new theoretical approach to interpreting effects and mechanisms of acupuncture in modern biomedical knowledge framework.

The Limbic-Prefrontal Network Modulated by Electroacupuncture at CV4 and CV12

fMRI studies showed that acupuncture could induce hemodynamic changes in brain networks. Many of these studies focused on whether specific acupoints could activate specific brain regions and were often limited to manual acupuncture at acupoints on the limbs. In this fMRI study, we investigated acupuncture's modulation effects on brain functional networks by electroacupuncture (EA) at acupoints on the midline of abdomen. Acupoints Guanyuan (CV4) and Zhongwan (CV12) were stimulated in 21 healthy volunteers. The needling sensations, brain activation, and functional connectivity were studied. We found that the limbic-prefrontal functional network was deactivated by EA at CV4 and CV12. More importantly, the local functional connectivity was significantly changed during EA stimulation, and the change persisted during the period after the stimulation. Although minor differences existed, both acupoints similarly modulated the limbic-prefrontal functional network, which is overlapped with the functional circuits associated with emotional and cognitive regulation.

Tempo-spatial analysis of vision-related acupoint specificity in the occipital lobe using fMRI: an ICA study

Functional acupoint specificity is one of the most debated topics in acupuncture neuroimaging research. Conventional studies investigating vision-related acupoint specificity empirically assume that acupuncture-induced hemodynamic response can be defined a priori and thus concentrate on distinguishing the spatial variations of response patterns across acupoints in the occipital lobe. However, evidence suggests that acupuncture-invoked BOLD signal changes are independent of a priori time shape. Additionally, temporal profiles reflect how a stimulus corresponds with the brain, implying the hemodynamic coherence induced by stimulation. Therefore, temporal information carried in acupuncture-related neural activity may be more crucial to specificity issues. This paper initiates the detection into tempo-spatial dimension and the goal of this study is to detect functional acupoint specificity by uniquely comparing the temporal activities of the occipital lobe among vision-related acupoints (VRA) and a non-acupoint (NAP). We utilized the independent component analysis (ICA) to extract temporal patterns of occipital response by stimulating a VRA, i.e. GB37, and a NAP. As an improvement over previous ones, another VRA, i.e., BL60 was employed to consolidate our findings. Results showed that although all groups showed V1 activity in the occipital lobe, dissociable temporal activities in this region categorized GB37 and NAP (r=0.05, p=0.64). This finding was replicable with regard to BL60 and NAP (r=-0.03, p=0.77). Intriguingly, stimulation at two VRAs induced highly correlated temporal activities (p<0.0001). This study adds positive evidence to the issue of vision-related acupoint specificity. The utilization of ICA and consideration of temporal dynamics may shed light on future studies.

Ancient Chinese medicine and mechanistic evidence of acupuncture physiology

Acupuncture has been widely used in China for three millennia as an art of healing. Yet, its physiology is not yet understood. The current interest in acupuncture started in 1971. Soon afterward, extensive research led to the concept of neural signaling with possible involvement of opioid peptides, glutamate, adenosine and identifying responsive parts in the central nervous system. In the last decade scientists began investigating the subject with anatomical and molecular imaging. It was found that mechanical movements of the needle, ignored in the past, appear to be central to the method and intracellular calcium ions may play a pivotal role. In this review, we trace the technique of clinical treatment from the first written record about 2,200 years ago to the modern time. The ancient texts have been used to introduce the concepts of yin, yang, qi, de qi, and meridians, the traditional foundation of acupuncture. We explore the sequence of the physiological process, from the turning of the needle, the mechanical wave activation of calcium ion channel to beta-endorphin secretion. By using modern terminology to re-interpret the ancient texts, we have found that the 2nd century b.c. physiologists were meticulous investigators and their explanation fits well with the mechanistic model derived from magnetic resonance imaging (MRI) and confocal microscopy. In conclusion, the ancient model appears to have withstood the test of time surprisingly well confirming the popular axiom that the old wine is better than the new.

Lung meridian acupuncture point skin impedance in asthma and description of a mathematical relationship with FEV1

Alteration in acupoint skin impedance is purportedly associated with health impairment. This study examined lung meridian acupoint skin impedance in healthy individuals and patients with controlled asthma and the relationship if any with Forced Expiratory Volume in 1s (FEV(1)). Twenty-eight subjects diagnosed with asthma and 28 age and gender-matched healthy subjects had their FEV(1) and skin impedance, at acupoints LU 7 (Lieque) and LU 9 (Taiyuan) on the lung meridian, measured. Skin impedance was significantly higher in subjects with asthma (p<0.05) and negatively correlated with percent predicted FEV(1) (r=-0.34 to -0.40, p<0.005). The Receiver Operating Characteristic (ROC) suggested the cutoff point for logarithm-transformed mean of skin impedance for asthma was ≥3.59 unit (sensitivity=82.1%, specificity=82.1%) (AUC=0.878, p<0.001). A regression prediction equation of asthma was derived. This study suggests that acupoint skin impedance on the lung meridian may reflect the asthma condition. The use of skin impedance as an adjunctive, objective assessment in asthma screening and treatment monitoring, warrants further investigation.

Selecting a control for in vitro fertilization and acupuncture randomized controlled trials (RCTs): how sham controls may unnecessarily complicate the RCT evidence base

OBJECTIVE

To examine the theoretical and methodologic rationales for the use of sham acupuncture controls in trials of adjuvant acupuncture for in vitro fertilization (IVF), and to identify the drawbacks of using a sham acupuncture control that may have its own effects on the pregnancy outcome.

BACKGROUND

Acupuncture has typically been tested in trials that evaluate subjective, patient-reported outcomes such as pain. Ratings of pain and similar subjective states can be strongly influenced by respondents' prejudgments, preferences, and expectations about treatment benefits. Therefore, controlling for these expectations or "placebo effects" by using a sham acupuncture control group is critically important in trials of acupuncture for pain-related conditions. This need for sham acupuncture controls in trials of acupuncture for pain-related conditions may have led to the belief that sham acupuncture is always the most "rigorous" control, and that it should therefore be used for all acupuncture trials, including trials of adjuvant acupuncture for IVF.

CONCLUSION(S)

In trials of adjuvant acupuncture for IVF, the outcome is pregnancy, which is entirely objective and unlikely to be affected by a patient's expectations of a benefit of acupuncture. Because it seems unlikely that an IVF patient's knowledge of whether she was receiving adjuvant acupuncture would affect her ability to become pregnant from IVF, using sham acupuncture to control for expectation/placebo effects seems unnecessary in this context. Even if adjuvant acupuncture were to increase IVF success rates only through a psychosomatic effect mechanism, such as by reducing stress, this stress-reduction effect would be integral to the working mechanism by which adjuvant acupuncture increases IVF pregnancy rates; therefore, it seems inappropriate to control for and separate out any such stress-reduction effect by using a sham control. Because of the risk that the sham is not an inert placebo but rather an active treatment that may affect the pregnancy outcome, using sham acupuncture as the control may unnecessarily confuse rather than clarify the interpretation of the effects of IVF adjuvant acupuncture. Using both theoretical concerns and epidemiologic evidence, researchers should carefully weigh the benefits and drawbacks of using sham acupuncture to blind patients in adjuvant acupuncture for IVF trials, and should question, rather than automatically accept, whether "placebo effects" are an important risk of bias in this context.

Review of evidence suggesting that the fascia network could be the anatomical basis for acupoints and meridians in the human body

The anatomical basis for the concept of meridians in traditional Chinese medicine (TCM) has not been resolved. This paper reviews the evidence supporting a relationship between acupuncture points/meridians and fascia. The reviewed evidence supports the view that the human body's fascia network may be the physical substrate represented by the meridians of TCM. Specifically, this hypothesis is supported by anatomical observations of body scan data demonstrating that the fascia network resembles the theoretical meridian system in salient ways, as well as physiological, histological, and clinical observations. This view represents a theoretical basis and means for applying modern biomedical research to examining TCM principles and therapies, and it favors a holistic approach to diagnosis and treatment.

The temporal-spatial encoding of acupuncture effects in the brain

BACKGROUND

Functional acupoint specificity is crucial to the clinical efficacy of acupuncture treatment, such as pain relief. Whether acupuncture needling at a peripheral acupoint produces distinct patterns of brain responses remains controversial.

RESULTS

This fMRI study employed the complex network analysis (CNA) to test the hypothesis that acupuncture stimulation at an acupoint correspondingly induced activity changes in one or more intrinsic or resting-state brain networks. Built upon the sustained effect of acupuncture and its time-varying characteristics, we constructed a dynamic encoding system with the hub anchored at the posterior cingulate cortex and precuneus (PCC/pC). We found that needling at two visual acupoints (GB37 and BL60) and a non-visual acupoint (KI8) induced a spatially converging brain response, which overlapped at the PCC/pC. We also found distinct neural modulations during and after acupoint stimulation. During this period, the PCC/pC interacted with a visual resting-state network in different patterns. Furthermore, there was a delayed functional correspondence between the intrinsic visual network and manipulation over the visual acupoints (i.e., GB37 or BL60), but not the non-visual acupoint (KI8) via the PCC/pC, implicating a specific temporal-spatial encoding/decoding mechanism underlying the post-effect of acupuncture.

CONCLUSIONS

This study provided an integrated view exploring the functional specificity of acupuncture in which both the needling sensation and the following neural cascades may contribute to the overall effect of acupuncture through dynamic reconfiguration of complex neural networks.fMRI, acupoints, posterior cingulate cortex, precuneus, temporal-spatial encoding, resting-state networks.

Is sham laser a valid control for acupuncture trials?

Methodological problems of acupuncture trials focus on adequate placebo controls. In this trial we evaluated the use of sham laser acupuncture as a control procedure. Thirty-four healthy volunteers received verum laser (invisible infrared laser emission and red light, 45 s and 1 J per point) and sham laser (red light) treatment at three acupuncture points (LI4, LU7 and LR3) in a randomized, double-blinded, cross-over design. The main outcome measure was the ratio of correct to incorrect ratings of treatment immediately after each session. The secondary outcome measure was the occurrence of deqi-like sensations at the acupuncture points and their intensity on a 10-fold visual analog scale (VAS; 10 being the strongest sensible sensation). We pooled the results of three former trials to evaluate the credibility of sham laser acupuncture when compared to needle acupuncture. Fifteen out of 34 (44%) healthy volunteers (age: 28 ± 10.7 years) identified the used laser device after the first session and 14 (41%) after the second session. Hence, both treatments were undistinguishable (P = .26). Deqi-like sensations occurred in 46% of active laser (2.34 VAS) and in 49.0% of sham laser beams (2.49 VAS). The credibility of sham laser was not different from needle acupuncture. Sham laser acupuncture can serve as a valid placebo control in laser acupuncture studies. Due to similar credibility and the lack of sensory input on the peripheral nervous system, sham laser acupuncture can also serve as a sham control for acupuncture trials, in order to evaluate needling effects per se.

The Problem of Metal Needles in Acupuncture-fMRI Studies

Acupuncture is a therapy based on sensory stimulation of the human body by means of metal needles. The exact underlying mechanisms of acupuncture have not been clarified so far. Functional magnetic resonance imaging (fMRI) has become an important tool in acupuncture research. Standard acupuncture needles, which are made of ferromagnetic steel, however, are problematic in acupuncture-fMRI studies for several reasons, such as attraction by the scanner's magnetic field, significant image distortions and signal-dropouts, when positioned close to the head or even heating due to absorption of radio frequency (RF). The aim of this study was to compare two novel types of acupuncture needles with a standard needle for their effect on MRI image quality. The standard needle severely reduced image quality, when located inside the RF coil. The nonferromagnetic metal needle may pose a risk due to RF heating, while the plastic needle has a significantly larger diameter. In conclusion, our recommendations are: (1) standard needles should not be used in MRI; (2) Nonferromagnetic metal needles seem to be the best choice for acupoints outside of the transmitter coil; and (3) only plastic needles are suited for points inside the coil. Laser acupuncture may be a safe alternative, too.

Methodological problems in FMRI studies on acupuncture: a critical review with special emphasis on visual and auditory cortex activations

Functional magnetic resonance imaging (fMRI) has been used for more than a decade to investigate possible supraspinal mechanisms of acupuncture stimulation. More than 60 studies and several review articles have been published on the topic. However, till now some acupuncture-fMRI studies have not adopted all methodological standards applied to most other fMRI studies. In this critical review, we comment on some of the problems including the choice of baseline, interpretation of deactivations, attention control and implications of different group statistics. We illustrate the possible impact of these problems by focussing on some early findings, namely activations of visual and auditory cortical areas, when acupoints were stimulated that are believed to have a therapeutic effect on vision or hearing in traditional Chinese medicine. While we are far from questioning the validity of using fMRI for the study of acupuncture effects, we think that activations reported by some of these studies were probably not a direct result of acupuncture stimulation but rather attributable to one or more of the methodological problems covered here. Finally, we try to offer solutions for these problems where possible.

Delayed Effect of Acupuncture Treatment in OA of the Knee: A Blinded, Randomized, Controlled Trial

To assess the efficacy in providing improved function and pain relief by administering 8 weeks of acupuncture as adjunctive therapy to standard care in elderly patients with OA of the knee. This randomized, controlled, blinded trial was conducted on 55 patients with OA of the knee. Forty-one patients completed the study (26 females, 15 males, mean age ± SD 71.7 ± 8.6 years). Patients were randomly divided into an intervention group that received biweekly acupuncture treatment (n = 28) and a control group that received sham acupuncture (n = 27), both in addition to standard therapy, for example, NSAIDS, cyclooxygenase-2 inhibitors, acetaminophen, intra-articular hyaluronic acid and steroid injections. Primary outcomes measures were changes in the Knee Society Score (KSS) knee score and in KSS function and pain ratings at therapy onset, at 8 weeks (closure of study) and at 12 weeks (1 month after last treatment). Secondary outcomes were patient satisfaction and validity of sham acupuncture. There was significant improvement in all three scores in both groups after 8 and 12 weeks compared with baseline (P < .05). Significant differences between the intervention and control groups in the KSS knee score (P = .036) was apparent only after 12 weeks. Patient satisfaction was higher in the intervention group. Adjunctive acupuncture treatment seems to provide added improvement to standard care in elderly patients with OA of the knee. Future research should determine the optimal duration of acupuncture treatment in the context of OA.

Different brain network activations induced by modulation and nonmodulation laser acupuncture

The aim of this study is to compare the distinct cerebral activation with continued wave (CW) and 10 Hz-modulated wave (MW) stimulation during low-level laser acupuncture. Functional magnetic resonance imaging (fMRI) studies were performed to investigate the possible mechanism during laser acupuncture stimulation at the left foot's yongquan (K1) acupoint. There are 12 healthy right-handed volunteers for each type of laser stimulation (10-Hz-Modulated wave: 8 males and 4 females; continued wave: 9 males and 3 females). The analysis of multisubjects in this experiment was applied by random-effect (RFX) analysis. In CW groups, significant activations were found within the inferior parietal lobule, the primary somatosensory cortex, and the precuneus of left parietal lobe. Medial and superior frontal gyrus of left frontal lobe were also aroused. In MW groups, significant activations were found within the primary motor cortex and middle temporal gyrus of left hemisphere and bilateral cuneus. Placebo stimulation did not show any activation. Most activation areas were involved in the functions of memory, attention, and self-consciousness. The results showed the cerebral hemodynamic responses of two laser acupuncture stimulation modes and implied that its mechanism was not only based upon afferent sensory information processing, but that it also had the hemodynamic property altered during external stimulation.

Global trends and performances of acupuncture research

This study was designed to evaluate the global scientific output of acupuncture research in the Science Citation Index-Expanded and to assess the tendencies and research performances of leading countries/territories and institutes. Articles referring to acupuncture were assessed by distribution of document types, languages, journals, subject categories, source countries, and source institutes. Results showed that 15 languages were represented in articles from 65 countries/territories. Journal of Alternative and Complementary Medicine published the most articles, followed by American Journal of Chinese Medicine and Acupuncture & Electro-Therapeutics Research which were listed in category of integrative & complementary medicine. In the study period of 1991-2009, USA was the top producing country, followed by China (mainland) with a sharply growth trend. In 2009, publication of China (mainland) ranked top one in the world. In addition, an acupuncture research trend was found in two phases in terms of the increase of number of SCI-expanded journals' articles. Among the acupuncture research, pain control has been the most prevalent direction of study, and brain imaging is attracting the most recent attention.

The languages of healing: linked by a common thread

Though separated by different millennia, languages, levels of scientific advancement, and views of human physiology, both prehistoric and modern cultures have expressed concepts of evaluating and treating human illness that have remarkable overlap with those of Traditional Chinese Medicine (TCM). These similarities suggest these healing traditions likely are expressing a common, fundamental aspect of human anatomy and/or physiology. Prehistoric, ancient Egyptian, TCM, Mayan, myofascial pain, and myofascial meridian concepts of health and healing are discussed. Anatomical, clinical, and physiologic evidence is presented that suggests neuroanatomy is likely the common thread that unites these ancient and modern healing concepts. These findings should lead to an increased understanding of the anatomical and physiologic substrates of the beneficial clinical effects of acupuncture in treating pain and visceral disorders. This, in turn, should lead to novel, safer treatment techniques that combine modern technologies with ancient clinical acumen.

Is acupuncture an acceptable option in stroke rehabilitation? A survey of stroke patients

OBJECTIVE

Stroke is a leading cause of morbidity and mortality and stroke survivors make up the largest group of patients in rehabilitation. These individuals also have one of the longest lengths of stay in rehabilitation. It has been suggested that acupuncture may be beneficial in post-stroke rehabilitation and in this study we examine how stroke patients value acupuncture and their perceptions of acupuncture as a rehabilitation treatment option.

DESIGN AND SETTING

A questionnaire was distributed to individuals undergoing post-stroke rehabilitation at three rehabilitation centers attached to hospitals in Toronto, Canada.

RESULTS

Two hundred and seventy-three individuals completed the questionnaire with the respondent group comprising mainly males (62%) over 65 years of age (68%). Overall 29% had used acupuncture with 16% receiving acupuncture treatment for stroke related conditions. Almost all respondents (98%) wanted to know more about acupuncture in stroke rehabilitation and 87% would consider acupuncture as a treatment option. Few (8%) reported that they had advanced level knowledge about acupuncture, with most reporting a basic (48%) or intermediate (33%) level which recognized that acupuncture used fine needles to produce a therapeutic response. Those with prior acupuncture experience expected to pay more for treatment. The main factors influencing decisions to use acupuncture were practitioner competency (84%), cost (65%) and sterilization concerns (40%).

CONCLUSION

This study demonstrates that there is willingness by patients attending conventional hospital-based rehabilitation centers to consider acupuncture in stroke rehabilitation and that lack of knowledge about this treatment is not a barrier to use.

The hybrid GLM-ICA investigation on the neural mechanism of acupoint ST36: an fMRI study

Ample clinical reports and neuroimaging studies have demonstrated that the acupuncture has sustained effects after manipulation. However, most previous fMRI studies of acupuncture have paid little attention to this issue, only investigating on the manipulation effects. In the current study, we attempted to explore both acupuncture effects, which have positive influence to therapeutic efficiency, to reveal the neural mechanism of acupuncture. This paper combined the conventional general linear model (GLM) and independent component analysis (ICA) to study the topography and the temporal feature of brain activity to detect the brain responses to stimulation at ST36 (Zusanli) and a sham acupoint. The results showed that the manipulation-related effects and the sustained acupuncture effects separately induced statistically significant increases/decreases in the cortical-subcortical areas, including the anterior cingulate cortex (ACC), ventrolateral prefrontal cortex (VLPFC), supplementary motor area (SMA) primary/secondary somatosensory cortex (SI/SII), occipital cortices and midbrain. Our findings suggested that the analgesia effects of ST36 integrated sophisticated physiological and psychological procedures. In addition, our results have shed light on methodology in acupuncture research.

Positron emission tomography analysis of the analgesic effects of acupuncture in rhesus monkeys

The purpose of this study was to examine whether pain-induced brain activation was suppressed by acupuncture analgesia. We investigated the suppression of the pain-induced neuronal activation in specific brain areas of three male rhesus monkeys (aged four years old) using positron emission tomography (PET), in which changes in the regional cerebral blood flow (rCBF) were examined as an index of the neuronal activation. The brain areas such as the thalamus, insula and anterior cingulate cortex were activated by heating the tail of monkeys in 47 degrees C water compared to the heating at 37 degrees C. Those activations were suppressed by electroacupuncture (EA) with a 2 sec alteration of the frequency of 4 Hz/60 Hz at the right ST36 (the upper anterior tibial muscle) and the right LI4 (the back palm between the first and second metacarpal) acupoints. Meanwhile, this EA analgesic effect was confirmed by prolonging the tail withdrawal latencies from hot water in the temperature range from 45 to 50 degrees C.These brain areas were corresponded to the pain-related areas as reported in previous studies. In conclusion, we were able to visualize the acupuncture analgesia in the CNS. We also detected the brain areas activated or inactivated by acupuncture. The areas that responded to acupuncture stimulation at 47 degrees C water were different from the regions at 37 degrees C. We consider that this difference in the response to acupuncture may support the variation of the clinical efficacy of acupuncture in patients bearing pain or other disorders.

Effects of scalp acupuncture versus upper and lower limb acupuncture on signal activation of blood oxygen level dependent (BOLD) fMRI of the brain and somatosensory cortex

OBJECTIVE

The objective of this article is to investigate brain activity of scalp acupuncture (SA) as compared to upper and lower limb acupuncture (ULLA) using functional magnetic resonance imaging (fMRI).

SUBJECTS AND METHODS

Ten (10) healthy right-handed female volunteers aged 20-35 were divided into 2 groups: a SA group and an ULLA group. The SA group had needles inserted at the left Sishencong (HN1), GB18, GB9, TH20, and the ULLA group at the right LI1, LI10, LV3, ST36 for 20 minutes, respectively. Both groups had tactile stimulation in the order of the right LI1, LI10, LV3, ST36 before and after acupuncture for a block of 21 seconds repeated 3 times. The blood oxygen level dependent (BOLD) fMRI was used to observe the brain and somatosensory cortex signal activation.

RESULTS

We compared the signal activation before and after acupuncture needling, and the images showed signal activation after removing the acupuncture needles and the contralateral somatosensory association cortex, the postcentral gyrus, and the parietal lobe were more activated in the SA group. The right occipital lobe, the lingual gyrus, the visual association cortex, the right parahippocampal gyrus, the limbic lobe, the hippocampus, the left anterior lobe, the culmen, and the cerebellum were activated in the ULLA group.

CONCLUSIONS

We concluded that there were different signal activations of BOLD fMRI before and after SA versus ULLA, which can be thought to be caused by the sensitivity of acupoints and the different sensory receptors to acupuncture needling.

Acupuncture Versus Venlafaxine for the Management of Vasomotor Symptoms in Patients With Hormone Receptor–Positive Breast Cancer: A Randomized Controlled Trial

Purpose

Vasomotor symptoms are common adverse effects of antiestrogen hormone treatment in conventional breast cancer care. Hormone replacement therapy is contraindicated in patients with breast cancer. Venlafaxine (Effexor), the therapy of choice for these symptoms, has numerous adverse effects. Recent studies suggest acupuncture may be effective in reducing vasomotor symptoms in menopausal women. This randomized controlled trial tested whether acupuncture reduces vasomotor symptoms and produces fewer adverse effects than venlafaxine.

Patients and Methods

Fifty patients were randomly assigned to receive 12 weeks of acupuncture (n = 25) or venlafaxine (n = 25) treatment. Health outcomes were measured for up to 1 year post-treatment.

Results

Both groups exhibited significant decreases in hot flashes, depressive symptoms, and other quality-of-life symptoms, including significant improvements in mental health from pre- to post-treatment. These changes were similar in both groups, indicating that acupuncture was as effective as venlafaxine. By 2 weeks post-treatment, the venlafaxine group experienced significant increases in hot flashes, whereas hot flashes in the acupuncture group remained at low levels. The venlafaxine group experienced 18 incidences of adverse effects (eg, nausea, dry mouth, dizziness, anxiety), whereas the acupuncture group experienced no negative adverse effects. Acupuncture had the additional benefit of increased sex drive in some women, and most reported an improvement in their energy, clarity of thought, and sense of well-being.

Conclusion

Acupuncture appears to be equivalent to drug therapy in these patients. It is a safe, effective and durable treatment for vasomotor symptoms secondary to long-term antiestrogen hormone use in patients with breast cancer.