Towards a Dose of Acupuncture Summary Although it would be quite unacceptable lo attempt most forms of treatment without defining the dose, acupuncture has so far remained without any means of quantification. Electrical and deep manual needling probably rely lor their main effect on direct nerve ancl muscle stimulation.lt is su1qested that superficial needling acts by prcducing a cone ol tissue damage, with releaseof inflammatorymediators which incrcase the sensitivity of local nerve endingsso that trivial, incidental stimulation continues to induce CNS inhibitory effects for a prolonged period. The degree of local inflammatory eflect can easily be recorded by measuring the area ol skinflare. A simple lormula is oflered to determinethe dose ol acupuncture, basedon skin flarc recordings after experimental needling and theoretical considera- tions ol tissue damage. Need/es of varying shalt radius were insertedto a number of depths in the abdominaldermis and subjected to specificdegrees of stimulation.The experimental data correlate well with the theoretical model. Needle response increases with depth of insertion,and with needle thickness although this is outweighed by the effects of manipulalionif carriedout. The lormula derived lor determining the dose of acupuncture which correlates with inflammatory response, as measured by skin flare, is (r + 0.11)K, where I is the radius of the needle shalt, I is the deplh of insertion and K is 10 for unmanipulated insertions ot I 2.4 il the needleis manipulated. Key words Acupuncturc, Dosage, Needle depth, Needle thickness, Skin flare. lntroduction It is a fundamental requirement of any form of medical treatment to quantify the amount given. We wouldn't dream of prescribing a drug without specifying the dose,and the dose/effect relationship and therapeutic ratio are basic pharmacological concepts. Quantification of physical treatments rs also takenfor granted, yet in acupuncture we talk only about where we apply the stimulus and the form this takes, for instance whetherit is manual Nov 1991vol 12 No.2 - - This pape| as presented al lhe BMAS Spring Scientific Meeting held at Cheltenham in May 1 991 needling or electroacupuncture. I beJieve we need to definea posology for acupuncture which takes account of the varialions of technique and allows a comparison of the overall magnitude of the stimulus 8iven. T heo rct i cal Consid e nti ons The insertion of an acupuncture needle causes tissue damage. Inflammatory mediators are reJeased and sensitise local nerue endingscausinga state of hyperaesthesia and hyperalgesia, such that afferent impulses bombard the centralnervous system fof some time afterwardsin responseto trivial, incidental stimulation at the siteof treatrnent. In the case of manuai needling, tissue damage is caused by the needle being inserted into the skin and subcuta neous tissue. Manipulation of the needle will cause only a slightincrease in trauma at the point in the epidermis throughwhich the shaft of the needle passes fFEUre /)- But, since it moves to a much greater extent in relation to the surroundinB tissLres, the tip of a needle which is beinB rnanipulated will causemuch more trauma. As it is moved it will impinge on an increasing number of cells causing them damage, untiJ a volume of tissue resembling an inverted cone has been affected. The baseof the conewill correlate to the pointof the needle, and its point to the site of needle entry into the skin.The volume of the conewill be greater if the direction of the needleis changed durinSmanipulation and if the needle is pushed in further and thenwithdrawn. If the needle is merelyrotated the volumewill be Handle - tf figurc L Cane of tissue<la|r,aue fron rctation as opposed ta lill .nd thtust bchnlque. Rotation Lift and A.upun.tDrein Medrcine on 12 November 2018 by guest. Protected by copyright. http://aim.bmj.com/ Acupunct Med: first published as 10.1136/aim.12.2.78 on 1 May 1994. Downloaded from
Transcript
Towards a Dose of Acupuncture
SummaryAlthough it would be quite unacceptable lo attemptmost forms of treatment without defining the dose,acupuncture has so far remained without any meansof quantification.
Electrical and deep manual needling probably relylor their main effect on direct nerve ancl musclestimulation. lt is su1qested that superficial needlingacts by prcducing a cone ol tissue damage, withrelease of inflammatory mediators which incrcasethe sensitivity of local nerve endings so that trivial,incidental stimulation continues to induce CNSinhibitory effects for a prolonged period. The degreeof local inflammatory eflect can easily be recordedby measuring the area ol skin flare.A simple lormula is oflered to determine the dose
ol acupuncture, based on skin flarc recordings afterexperimental needling and theoretical considera-tions ol tissue damage. Need/es of varying shaltradius were inserted to a number of depths in theabdominal dermis and subjected to specific degreesof stimulation. The experimental data correlate wellwith the theoretical model. Needle responseincreases with depth of insertion, and with needlethickness although this is outweighed by the effectsof manipulalion if carried out.
The lormula derived lor determining the dose ofacupuncture which correlates with inflammatoryresponse, as measured by skin flare, is (r + 0.11)K,where I is the radius of the needle shalt, I is thedeplh of insertion and K is 10 for unmanipulatedinsertions ot I 2.4 il the needle is manipulated.
lntroductionIt is a fundamental requirement of any form ofmedical treatment to quantify the amount given. Wewouldn't dream of prescribing a drug withoutspecifying the dose, and the dose/effect relationshipand therapeutic ratio are basic pharmacologicalconcepts. Quantif ication of physical treatments rsalso taken for granted, yet in acupuncture we talkonly about where we apply the stimulus and theform this takes, for instance whether i t is manual
Nov 1991vol 12 No.2
- -
This pape| as presented al lhe BMAS Spring Scientific Meeting held at Cheltenham in May 1 991
needling or electroacupuncture. I beJieve we needto define a posology for acupuncture which takesaccount of the varial ions of technique and al lows acomparison of the overal l magnitude of the stimulus8iven.
T heo rct i cal Consid e nti onsThe insert ion of an acupuncture needle causes t issuedamage. Inf lammatory mediators are reJeased andsensit ise local nerue endings causing a state ofhyperaesthesia and hyperalgesia, such that afferentimpulses bombard the central nervous system fofsome time afterwards in response to tr ivial,incidental st imulation at the site of treatrnent. In thecase of manuai needling, t issue damage is caused bythe needle being inserted into the skin and subcutaneous t issue. Manipulation of the needle wil l causeonly a sl ight increase in trauma at the point in theepidermis through which the shaft of the needlepasses fFEUre /)- But, since it moves to a muchgreater extent in relation to the surroundinB t issLres,the t ip of a needle which is beinB rnanipulated wil lcause much more trauma. As it is moved it wil limpinge on an increasing number of cel ls causingthem damage, untiJ a volume of t issue resemblingan inverted cone has been affected. The base of thecone wil l correlate to the point of the needle, and itspoint to the site of needle entry into the skin. Thevolume of the cone wil l be greater i f the direction ofthe needle is changed durinS manipulation and ifthe needle is pushed in further and then withdrawn.If the needle is merely rotated the volume wil l be
Handle
- t f
figurc L Cane of tissue <la|r,aue fron rctation as opposed ta lill.nd thtust bchnlque.
less; and it wil l be least i f the needle is simplyinserted and withdrawn. The difference betweenthese two methods of manipulation wouid be due toinadvertent movement of Lhe t ip of the needJe inaxes paral lel to and at r ight angles to the plane ofinsert ion when the needle is rotated, due to f inetremor of lhe operator's hand. A purely rotatorymovement would cause very Jit t le extra t issuedamage than simple insert ion and withdrawalwithout manipulation.
Duration oI inserl ion per se should have l i t t le effecton the strenglh of the stimuius, whereas duration ofmanipulation might have a siSnif icant effect up tothc t ime when the needJe had travelled through itsmaximum distance in al l directions and thus hadtraumatised the largesl voiume cone of t issue. Thiswil l probably occur within the f irst few seconds andprolongation of rnanipulation beyond this pointwouid not increase the t issue damage signif icantly.However prolonBed manipulation mechanicaliystimulates skin and muscle nerve endings, whichmay be some distance from the needle, due tovibration of adjacent, non traumatised t issue. ThisprolonSed mechanical st imulation woulcl seem tobe necessary for the development of surgicalanalgesia and in some other situations such asalleviation of withdrawal symptoms. Prolongedstimulation can also convenientJy be achieved elec-tr ical ly.
Volume 0.00023cm3 T': 'I
fi?urc 3. Etfe.:t of depth of inseftion on dana7e arca.
highly innervated dermis, and on the assumptionthat needling some other subcutaneous structurewell supplied with nerve endings, such as muscle orperiosteum, does not occuf ( i .e. at most skin si les),the extra volume of subcutaneous t issue traumatisedby the needie wii l be of relatively Jit t le imporlancein determining the magnitude of the sl imulus.In theory, when an acupunclure needle is inserted
to a f ixed deplh and lhen removed without manipu-lal ion, the volume of t issue damaged is described bythe formula z / / where r is the radius of the needleand / is the depth of insert ion. Note that as thedamage is related to the square of the radius, therelationship between needle radius and stimulationis not rectilinear (Figure 1). A needle of 0.2mmradius inserted to a f ixed depth and then withdrawnwithout manipulation causes four t jmes the t issuedamage of a needle of 0.1mm radius i f movem€ntdue to tremor is discounted. During rnanualstimulation though, the major mechanism of t issuedamaSe is t ip trauma, and againsl this the effect olthe thickness of the needle should be relativelyminor. Even when the needle is not pLrrposelyrnanjpulated, hand lremor results in movements otfar Breater signi{icance than the effect of differingneedle thickness.Bearing these various considerations in mind we
can derive theoretical ly a single measure otacupuncture dose for manuaJ needling, which mightbe called the Unit of Acupuncture (UA). This wouldencompass the factors of duration of manipulation
Depth of insert ion may affect the degfee of t issuedamage in perhaps an unforseen way. A needleinsefted to 2cm and withdrawn withoul manipula-t ion wil l traumatise twice the voJume of t issuecompared wilh one of the same diameter insefted to1cm (Figure 2). Bul some manipulation is almostinevitable because of hand tremor, and it may becarried out purposely. In either case, through theprinciple of levers, the arc described by the t ip ofthe more deepJy inserted needle would be muchgreater, and therefore the t issue damage caused alsomore profound (FiSure 3). Depth may also beimportant since different subcutaneous planes maybe penetrated, for instance muscle of periosteumrather than subcutaneous fat. The inrrervauc'n c-rrthese structures differs, as is easily recognised by thedifferent needling sensation caused, so differentnervous effects may be expect€d. l t seems l ikely thatprovided the acupuncturc needle penetraLes the
AcupuD.tute iD Medi.ine
Volume 0.00046cmr
2cm
FigLrc 2. Valune of tlstue dantage with diltercnt insertiondepths, fot an uDnlanipulated needle al tudas 0.1oanm.
v o l m e o r 1 s $ a d a n a q e ( . m )
N@do dius Gn)
t:isure 4. Nccdle radius and valuneai jssuedanase for a tcini n scrtion \| | th out n a n i pu I at i on.
by a method which does not greatly change theposit ion of the needle in the dermis; clepth ofi fsert ion for othef than very shallow (cutaneous)insert ion; and needle radius weighted appropriately.-fhus
a theofetical fofmula might 6e (r + 0.l l) Klvherc:r = needle radius ir mm alablc ir)/ = dcplh of inscrt ion in cmK= l5 i f t he need le i s man ipu la ted fo f 5 seconds o f
mofc; or l0 j f there rs less than 5 seconds ofn ran ipu la t i on .
Example L For a needJe oi 0-2nrnr radius insertcdI cm and withdrawn without manipulation(regardless ol the dural ion of insert ion) thc closc s:( 0 . 2 + 0 . 1 ) 1 0 = : J U A
Exan)plc 2. For a nccd c of radius 0.2mm inserted tol cnr and rolaled lor I Osec the dose is:(0 .2 + 0 .1 )15 = ,1 .5UA
Ex;tnpl-^ 3. For n needl-. oi 0.2mrr radius insened tol cm and rolated ior 5min lhe dose is also.( 0 . 2 + 0 . 1 ) 1 5 = 4 . 5 U A
Exar. 'pl,^ L For a needle ol 0.: lmm racl ius inserted to2 , lFp lL r -n l r r ' ' r i 1 . J l p l f o r n r i r r a L r . I 6 |f lying techniqLre the dose is:( 0 . 3 + 0 . 2 ) 1 5 = / . 5 U A
ValidationDeriving the above relationship theoretical ly hassome value jn ioausing al lention on thc variousco r rponen ls o I t he acL ]punc lu re s l imu lus wh ichdel-.rmin-. i ts magnitude. l l is argLred lhar thenumerical values are corect at least lo within anorder ol magnitude, bul more precise quanti l ical ionmLrsl depend on experinrenlal measurcmcnt. lnother words we need an acLrpunclure assay. l l wi l lnot be satisfrctory to nssess stimulus inlensily byrecording the "end o!l lan" effecl of sl ir .ulal ion, forinstance by cornparing the efiects ol lhe maripula-t ion parameters on the elevation oi dental painthfeshold. Ph\,siological constrir ints may alter themathcmatical relationship between stimulus andeffect nragnitude, or rnay altogether prevent theeifect being nraniiest. To mcasufe the effects ofacupunciurc closer to thc site of the stimulus, lofexample by rccording ncural traff ic in At f ibresrunning irom the site of necdlinS, would be better,bul the characlerist ics of lhe receplors or nervescoulcl modify transmissior] ol af lerent impulsesunpreclicfably. Sorre paradigm ol l issue dnmage isneeded. A possibi l i t) , would be to examine animal
Nor 19r):l Vol 12 Na.2
t issue histoloBically after needling, but this worldirttract the usual concems about the applicabil i ly ofanimal data to the hurnan sitLral ion. A surrogateendpoint colr ld be the release of one or moreinflarnmatory mediators- A microassay woulcl beelegant, but technical ly diff icult.
In suscepiible subjects the efiects of mediatorrelease (principally histamine) in the skin fol lowinBneedling are obvioLrs by vir lue of the vasodilalal ionrvhich is caused. A red f lare rapidly spreads irom thesitc of needle inseft ion. l t lasts ior half an hour or soaftcr renroval of the needle, and in some cases rsaccompanied by a small central area of blanchingand even a small wheal at the puncture site: aclassical "lewls Triple Response". A series of pilotexperiments n,as carried out on an individLralsubjcct to cofrelate the area of sl<in f lare lvith themagnitude of acupuncturc st irrulus under contfol ledcondr t rons .
Methodln an individual volunteer an init ial study wasunderlaken 1() determine thc t imc course of ther , . , . nd | . t r n r . l L " ' 1 " e r " r ^d ,o rpp .approxinrately 30 seconds alter needle insert jon andr,vas ful ly developed 90 seconds later. Flarediarneters were therelore lhen measured trvominutes al ler repealed needling in lhe sanreindjvidual at a site susceptib e to this reaction: theskin of thc latcral abdomen between the costalmargin and the i l iac crest. C)bservations werecarried out at room temperature on each occasionand ambicnt air tcmperatufe rvas recordecl. Themcan of trvo diametefs at 90 degrees to each otherwas recorded. Standard stainlcss stec necures(A.uMedi.) of di l ierefl radi i were jnscrtcdaccurately to the desired deplh $,i th the aid of guidctlrbes- Skin antiseplics were r]ot used- Stirnulationwrs carried out for specii ic t jmes Lrsing either simplc'u l . r l L r u r r71 , , ' 5 c r r r r l ' p . Ro r rn r r r r r .acconrpl ished by grasping the needle betweenfingcr and thumb and fotating i t approximately 45dcgrccs onc way and then back, takinE care loprevenl inadvcftcnt deeper insert ion. A check oninseft ion dcpth was faci l i tated by a marl( on theneedle shaft. "Flying" the needle consisted oirolation in the samc way, but with the neecllereleased al lhe end of i ts rnoverncnt, so skin tensionand elasticity ret!rned it to thc neutral posit ion. Fivefolal iofs in one direction r,vcrc fol lowed by f ive inthe olher, and so on, lor lhe period of st i lnulation.
l l-" f^l o"r ,B a\pFr,mon ol ord ionr ' ,r n .Stuoreo:
. r . Need les o f 0 .100 , 0 .140 , and 0 .175mm rad iusinserted to 0.5crn nnd retained 2 r. inules wilhouLmanipulation. (UA eqLrivalents according lo lheabove calculationr 1 .5, 1-9 rnd 2.25 respeclively.)b. Nccdlcs of 0.140mm fadiLrs inserted to 0.25,0.5, {1.75 and l.0cm depth and retained for 2m inu tcs w i thou t man ipu a t i on . (1 .65 , 1 .9 , 2 .15and 2.4UA rcspcctively-J
c. Needles of 0.140mm radius insertecl to 0.5cmdep lh , ro ta ted fo r 5 , 10 , 15 ,30 ,45 ,60 o r lB0seconds and then removed. (AlI 2.B5UA.)d. Needles of 0.175mm radius inserted to 1.Ocmclepth, " i lown" for 15 seconds and then removed:a max ima l s t imu lus . (4 .13UA- )
Five insert ion sites were uti i ised on each side of thcabdomen at each session, al lowing ten condit ions tobe slLrdied. At least f ive days separated each experimental session. When al l of the condit ions had bcenstudied, the process \!as repeated in i ts cntir€ly solhat two sets of obse^/al ions were available for eachcondit ion. The order of al l observations wasallocated using compLrter generatecl randontnumDerS.
ResulfsIn series a, using needles of diffefent thicknesses tothe same dcpth wilhout manipulation, i lare areaincreased with increasinS radius in a way lFigule.5)which closcly resembled the theoreticaJ predict ions(FiUurc l l) . Dtsaomiott on insert ion increased signif i-cantly with incfeasinB thickness.
nq r . i&$km)
Flgurc 6. tnsettun depth and area Dfflarc far o.tlantnt.a.h$nc€dle with 6As..: nt5,-ttbn, no nanipulatian.
rilLrc 7. Duation of n)inipol,nion and arca ai llatp rclA. 1 4Ann ra.lius ne-"dle A.5.m dcpth.
Fi|.u.e 5 Ne.-.11e ndiLts and area ai ilarc \'ith A.scn, 6asccinse ta., ha nr,rnipuIatian.
Jn s€ries b, \r ' , ,here needles of radius 0-140rnrn wereinserted lo foLrr different dcpths, l lare area incfeasedwilh depth, although l ineariry could not beconlirnred in this pi lot cxperiment aF,S{/re 6J.In series c, whefe 0.l40mm needles wefe inscrted
to 0-5cm and manipulated for seven ditterent ttmesbetween 5 and l8osccs fFEUre 7) f lare arca wasincreased from thal caused by insert ion wilhoutmanipulation, bul appeared to be independent ofmanip(l lat ion t ime. "Flying" as opposed 1() rotationlor the same time did not appear to in.rease theinflammatory response. Nor did the "marimalstimr//us" uti l ising a needle of 0.175mm radiusinserted to lcm cause an incrcased area of { lare
lf f larc area ior non manipulative inseft ions isp otted againsl dose in UA, a slraight l inecorrelation can be shown (F/gr/rc 8J, support ing thetheoretical calculations. The mcan area o{ { lare formanipulated insert ions gives a dose equivalent to2.35UA, lvhich leads to lhe conclusion that K formanipulaled needling in the lorrnula shoLrld be 12.4a n d n o l I 5 .
A.upunct! e in M..liclne
Conclusions1. Within the l imits tested on a single, volunteersubject (radius 0.100 to 0. J /5mm, inse(ion 0.25 toL00cm, anterolateral abdomen, roonr temperatufe)post needling f lare arca appears lo correlate wellwith theoretical models of the amount of loca t issuedamage caused by needling.
2. Based on these expcfimenls lhe formula fof anAcupuncture Unit of dose remains: ar + 0.l l)K, brIthe numerical value for K in the casc of manualmanipulatjon lor i ive seconds or longer should berevised to 12..1.
3. Stimulus strenglh would appear to increase withnccdlc radius Lrnless manipulation is carried out,\r ' , ,hen the eflect of this outweighs needJe thickness.Sincc thi.ker neeclles are signii icanlly more painfulto the palienl, ancl more l ikely lo caus-^ bruising, i t
may be better to use a thinner needle with manipu-lation to achieve the same effect.
4. Stimulus strength increases in proport ion to thedepth of insertion-
5- Manipulation for more than five seconds does notappear to increase stimulus strength, although theremay be other reasons for lonSer manipulation.
DiscussionThe work reported here is only a pilot study andneeds to be repeated on further subjects. Whilst itmay be possible thereby to confirm an associationbetween stimulus strength and skin inf lammation, i twil l then be irnpo4dnt lo rorrelate the degrpe orinf lammation with therapeutic outcome in a numberof suitable models.It is a mafter of common cl inical experience that
the skin reaction produced by acupuncture maydiffer considerably between posit ions on the body-For instance the abdominal skin (Lrsed here) or facialskin reacts more readily than that on the lower l imb.It follows that, to obtain a similar effect fromdifferent points, one should give stimuli of dif ferentstrengths. l t is also well known that one individual 'sskin reaction may be stronger than another's.Anecdotally it is often stated that a clear flare andwheal typifies the 'tfrong reactor" to acupuncture,making therapeutic response more l ikely at a lowerintensity of treatment. There is a {urther possibi l i tythat the deBree of inf lammation shows circadianvariat ion. NeedlinB into subcutaneous t issues suchas muscle, l igament or periosteum is not amenableto quantif ication by monitoring skin inf lammation,as different nerve pathways are involved and theireffects are often of great therapeutic importance.Thought wil l need to be Siven to a way ofdescribing the strength of these methods ofst imulation.All these questions, and many others about
acupuncture treatment, remain to be answered byappropriate experiments. Meanwhile, what st imulusvariables should be reported in any paper onacupuncture to al low if necessary post hog quan-t i f ication of the dose applied to cutaneous points?Apart from the nomber and location of the pointsused, they are the radius (or diameter) of the needle,the depth of inseft ion, whethef manipulated and ifso by which technique and for how long, andwhether post needling massage was performed. l f askin antiseptic such as alcohol is used, this shouldbe recorded since it could i tself inf lame the skin,especial ly i f applied after needling. Different pointsmay be needled to different depths and for differentdurations with and without manipulation, so a doseper point can be recorded or the total for a giventreatment session computed,
Paul Marcus MD FFPMNewton House, Newton LaneWhitlev Waffington WA4 4lA
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